|Year : 2021 | Volume
| Issue : 4 | Page : 219-226
Comparative effects of stretching exercises and core stability exercises in patients with chronic non-specific low back pain: A review of randomized clinical trial
Obinna Dickson Nwodo1, Peter Olarewanju Ibikunle2, Nnenna Linda Ogbonna3, Chinenye Joy Eze4, Godwin Uroko Ezeja1
1 Department of Physiotherapy, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
2 Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Anambra State, Nigeria
3 Department of Medical Laboratory, Enugu State University of Science and Technology Teaching Hospital, Enugu, Nigeria
4 Department of Pharmaceutical Science, University of Nigeria, Nsukka, Enugu State, Nigeria
|Date of Submission||30-Jun-2021|
|Date of Decision||13-Jul-2021|
|Date of Acceptance||17-Jul-2021|
|Date of Web Publication||19-May-2022|
Dr. Obinna Dickson Nwodo
Department of Physiotherapy, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State
Source of Support: None, Conflict of Interest: None
Exercise is known to be beneficial in the management of chronic low back pain (LBP), especially in pain reduction and improving function. Core stability exercise (CSE) is fast becoming the foremost exercise in the management of LBP; however, it is presently undetermined whether CSEs produces more valuable effects than stretching exercises in the management of LBP. The study aimed to review the effectiveness of CSEs or stretching exercises in the management of chronic LBP. A systematic review of randomized clinical trials was done using published articles. Multiple databases and specific journal websites were searched to obtained original researches published between 2000 and 2021 in which pain and disability were evaluated as outcomes. Methodological quality was assessed using the Physiotherapy Evidence Database scale and none of the included studies had scores of <9/10. Three studies met the criteria for this review. The included studies randomized participants into two different exercise groups. One out of the three studies showed benefits of CSE over stretching exercises for pain and disability. Another study showed ST exercise is more beneficial to CSE for pain and disability while the last study shows both CSE and ST exercises to be effective in pain and disability management. In conclusion compared to ST exercise, CSE is not more effective in pain reduction and improved physical function in individuals with LBP in the short term. However, no follow-up assessments were done postintervention.
Keywords: Core stability exercise, low back pain, stretching exercise
|How to cite this article:|
Nwodo OD, Ibikunle PO, Ogbonna NL, Eze CJ, Ezeja GU. Comparative effects of stretching exercises and core stability exercises in patients with chronic non-specific low back pain: A review of randomized clinical trial. Niger J Exp Clin Biosci 2021;9:219-26
|How to cite this URL:|
Nwodo OD, Ibikunle PO, Ogbonna NL, Eze CJ, Ezeja GU. Comparative effects of stretching exercises and core stability exercises in patients with chronic non-specific low back pain: A review of randomized clinical trial. Niger J Exp Clin Biosci [serial online] 2021 [cited 2023 May 29];9:219-26. Available from: https://www.njecbonline.org/text.asp?2021/9/4/219/345552
| Introduction|| |
Low back pain (LBP) is a serious health challenge affecting adults of prime working age of any nation most especially developing countries such as Nigeria.,,, LBP patients commonly present with decreased functions. Based on the recent clinical guidelines, exercise programs should be instituted in individuals with LBP., Stretching exercises have been beneficial in LBP rehabilitation; however, core stability (CS) training is fast becoming a popular rehabilitation regimen in the management of LBP., Till date, no review has been published on the comparative effectiveness of stretching exercise and CS training in the management of LBP patients.
| Methodology|| |
A systematic review was undertaken to locate, evaluate, and summarize the findings from randomized controlled trials (RCTs) that have investigated the effectiveness of CS exercises (CSEs) and stretching exercises in patients with LBP. A systematic review was chosen over a narrative review as it limits bias and error in the selection and appraisal of evidence.
We identified RCTs by electronically searching the following databases: PubMed, Medline, Google Scholar, and Physiotherapy Evidence Database (PEDro). Furthermore, we conducted a hand-searching of the reference lists of the articles found from the databases and journals to identify additional relevant articles. We restricted our searches to only studies published in the English Language between the years 2000 and 2021. We arrived at the decision to eliminate the cost of language translations and to ensure that the identified and included articles in this review would not be studies that are too staled. Briefly, the following medical subject headings were included: LBP, sciatica, lumbosacral region, exercise, and chronic pain. The keywords used were RCTs, double-blind method, single-blind method, random allocation, pelvic girdle pain, motor control, stretching exercises, static stretching exercise, dynamic stretching exercise, flexibility exercise, conventional exercise, specific exercise, and physical therapy. We removed duplicates that were identified in multiple database searches. All the literature searches in the afro-mentioned databases and journals were performed between January and May 2021.
Types of studies
Only RCTs examining the effectiveness of CSEs and stretching exercises in the management of patients with LBP were included.
Types of participants
We included articles with both female and male participants (18 and 60 years) who had LBP of not <3 months and also we excluded articles that included participants with LBP evoked by specific conditions or pathologies.
Types of interventions
We included articles that a group received stretching exercise and the other CS training. Stretching exercises entails moving the muscles and joints through their full range of movement to promote and maintain the functional autonomy. It could be static and dynamic stretching. CS training is the exercise that involves the spine and core muscles (mostly the transversus abdominis or multifidus), where the core muscles are tightened to while the spine is being stabilized and then progressed to functional activity.
Types of outcome measures
The primary outcomes of interest were pain intensity and disability
Selection of studies
Two reviewers (Nwodo Obinna and Ezeja Godwin Uroko) used the prespecified criteria to screen for relevant titles, abstracts, and full papers. An article was removed if it was determined not to meet the inclusion criteria. If these two reviewers reached different final selection decisions, a third reviewer (Ogbonna Linda Nnenna) was consulted.
We extracted the following data from the included articles: Study design, subject information, description of interventions between the CSE and stretching exercise group, follow-up period, and outcome measures. These data were then compiled into a standard table. The two reviewers (Nwodo Obinna and Ezeja Godwin Uroko) who selected the appropriate studies also extracted the data and evaluated the risk of bias. It was necessary to consult an arbiter (Ogbonna Linda Nnenna) to reconcile any disagreements.
Assessing the risk of bias
We used physiotherapy database score to assess the risk of bias for all articles. The following information was evaluated: Random sequence generation, allocation concealment, blinding of participants and personnel, blinding of therapist, etc. Two reviewers (Nwodo Obinna and Ezeja Godwin) evaluated the methodological quality of all articles examined in the current study. An arbiter was consulted (Ogbonna Linda Nnenna) to reconcile any disagreements.
| Results|| |
The process of identifying eligible studies is outlined in [Figure 1]. One hundred and twenty-nine records were initially identified through the PubMed, Medline, Google scholar, PEDro, and others. Of these, 14 potentially eligible articles were included based on their title and abstract. After reviewing these 14 potential articles, only three articles fulfilled the inclusion criteria.,, The remaining 11 articles were removed because the trials included participants with diagnoses other than chronic LBP, did not compare CSE with stretching exercise, or the original data were not available from the authors.
|Figure 1: PRISMA diagram of the search strategy and study selection processes|
Click here to view
Studies were included if they were RCTs on efficacy of CS training and stretching exercises in CLBP management, published in English between 2000 and 2021. Included patients were between the age of 18 and 60 years. Below are the individual characteristics of the included studies [Table 1].
CSE is the exercise that involves the spine and core muscles (mostly the transversus abdominis or multifidus), where the core muscles are tightened to while the spine is being stabilized and then progressed to functional activity. Stretching exercises entails moving the muscles and joints through their full range of movement to promote and maintain the functional autonomy. It could be static and dynamic stretching.
Data synthesis involved the combination and summary of findings of the studies selected for the review. The synthesis of the data was done by the descriptive synthesis using the extraction form designed by the reviewer to outline characteristics of the studies [Table 2].
The selected studies for the review were appraised using the PEDro scale [Table 3]. The methodological quality of all selected studies for the review was strictly assessed by two independent reviewers (Nwodo Obinna and Ezeja Godwin) with blinding.
In clinical trials, randomization is very important in assigning participants into groups and helps in providing rigor in the results and data interpretation. Chan et al. randomly assigned the participants into the CS group and dynamic stretching exercise group, Bolarinde et al. randomly assigned participants into stretching exercise with back education group, lumbar stabilization exercise with back education group and back education group and Franca et al. randomized the participants into two; segmental stabilization and stretching groups.
Allocation concealment is a way of blinding the group in which participants fall into assisting in minimizing selection and confounding bias in a study. All the studies utilized in this review used concealed allocation process.,,
In the presentation of clinical trials, a prognostic variable should be described for each treatment group. All the studies included in this review shows patient characteristics of key outcome measures at baseline.,, Similarly, in all the included studies of this review within the groups, experimental and control groups baseline characteristics were reported.
Blinding in research (participants, therapist, and assessors) is particularly important in the elimination of bias challenges that might occur after randomization., In this particular review, two of the included studies blinded their assessors, while Bolarinde et al. did not state whether the assessors was blinded or not. All the studies used in this review did blind their therapists and participants.,,
Intention-to-treat analysis is done with the intent to eliminate bias which predicts assumed differences among treatment groups., All the studies included performed intention-to-treat analysis.,,
All the included studies reported measure of outcome from 85% of the participants initially allocated to groups.,, All the included studies reported the results of between group statistical comparisons (P value) within all the primary outcome measures.,,
A point measure is considered a measure of the size of treatment effect. The included studies provided satisfactory level of point measures and measures of variability of their study standard deviations, confident intervals, standard errors, and quartile range.,,
Eligibility criteria help in providing heterogeneity in a study unless there is potential to enroll the population with certain characteristics. The included studies specified their eligibility criteria.
Two studies, used Oswestry disability index (ODI) and Visual Analog Scale (VAS) as outcome measures to ascertain disability level and pain intensity level, respectively, however, Chan et al. used numeric pain rating scale and ODI to assess pain intensity and functional ability, respectively.
Stage 5: Collating, summarizing, and reporting the results
Descriptive summary of the results
Three peer reviewed studies were included in this review [Table 4]. The studies were published in three countries: Nigeria, Brazil, and Malaysia.
Research designs used by the included studies
The research designs adopted by the included studies were randomized controlled study.
Aims/purposes of most of the included studies
The review aimed to determine the effectiveness of CSEs and stretching exercises in the management of LBP patients.
Populations of the included studies
Among the three included studies, all were carried out among LBP population; however, one of the studies was on work-related LBP. The total number of participants across all studies was 159 LBP individuals with a sample size range of 30–86.
The age of participants
Participants in the entire review were within the age range of 18–60 years. Participants were adults with LBP in line with the inclusion criteria of this review.
Franca et al. and Bolarinde et al. used both ODI and VAS as outcome measures for disability and pain intensity, respectively; however, Chan et al. utilized NPRS to determine pain intensity and ODI to ascertain disability level.
Duration of intervention
The duration of the interventions in the studies included in this review was about 30 min per each session, twice a week for at least six weeks to eight weeks.
Of the three studies included, two reported dropout of participants during the study period. Only one study reported one reported non withdrawal [Table 5].
CSE versus Stretching Exercise on Pain Intensity and Disability level.
In total, two trials, assessed pain intensity using visual analog scale (VAS) and disability level using ODI; however, Chan et al. assessed pain intensity using the Numeric Pain Rating Scale and disability level using ODI. Franca et al. indicated that CSE was better than stretching exercise for short-term pain relief and reduced disability level. This is in contrast with the findings of Bolarinde et al. who found that stretching exercise with back care education are more beneficial in temporary pain relief vis a vis disability level than CSE with back care education and back care education alone. Chan et al. reported that both CSEs and dynamic stretching are both beneficial in the reduction of pain and disability level.
| Discussion|| |
This review used a systematic review of RCTs to determine the effectiveness of CS training and stretching exercises in the management of CLBP. Franca et al. reported that both CS and stretching exercise reduces pain and disability among CLBP (P > 0.05) with CS training being more beneficial. Intermediate and long-term effects were not determined as there were no follow-up periods. The mean and standard deviation of the VAS score of 0.06 ± 0.6 in the CS training group (CT group) and 3.15 ± 1.20 in the stretching exercise group (ST group) and ODI score of 1.80 ± 1.26 in the CT group and 3.15 ± 1.20 for ST group. The result showed no statistical significant difference among the two exercise groups. The intervention lasted for 6 weeks with two participants dropping out of the study and the reason not stated. The study utilized quite a number of participants, and they were blinded and randomly assigned into two groups; hence, it has significantly reduced selection bias which might affect the internal validity of the study. The participant's characteristics were similar at baseline hence improving the strength of the outcome of the study. In spite the dropouts and long duration of the study, the measures of outcome were obtained from 93% of the participants which has added to the internal validity of the study.
Bolarinde et al. reported CSE is more effective than stretching exercises and control group in the management of CLBP, although it is important to note that the groups received back care education at baseline. The mean and standard of the VAS score of 23.95 ± 4.03 in the CT group, 16.55 ± 3.62 in the ST group, and 28.22 ± 4.61 in the control group and ODI score group of 10.37 ± 3.28 in the CT group, 4.69 ± 2.29 in the ST group and 11.07 ± 2.86 in the control group. This study had the greatest number of subjects which adds to part of the strength of the study, and despite the long duration of the intervention, there were 10 dropouts in this study. Furthermore, one of the weaknesses of this study is none follow up to ascertain the intermediate and long term effect of the exercise however this study has added positively to the evidence of using CS training in the management of LBP. Another weakness of this study is the fact that the therapists were not blinded, this perhaps can affect the result of this clinical trial but the participants and the assessors were blinded though.
Chan et al. reported that both CS training and dynamic stretching regimen are effective in the management of CLBP without recourse to any exercise being more beneficial. The mean and standard deviation of VAS score in the computed tomography (CT) group are 3.30 ± 0.95, 2.60 ± 0.71 in the dynamic stretching regimen and 5.50 ± 1.84 in that of the control group. ODI score group of 20.70 ± 6.93 in the CT group, 17.80 ± 6.55 in the dynamic stretching group and 46.50 ± 13.13 in the control group. To ensure internal and external validity of this study, they randomized their participants into groups with concealed allocation to minimize bias in the study. Furthermore, the result of this study also gained credibility due to proper blinding of the assessors, therapists, and participants and reportage of the measure of variability. There is a good credibility in the sense that there were no dropouts in the study all through the 6 weeks of intervention. However, the study lacked follow-up; therefore, intermediate and long-term effect of the exercise perceived remained unknown.
All three studies critically appraised above have sound internal validity which makes the results of the studies acceptable and can be used as evidence in future practice.
The quality of this review may have been negatively impacted due to inability to include other studies that were reported in other languages other than English and age range of the participants was restricted to 18–60 years only likewise the year of publication which was restricted to the year 2000 and 2020. PEDro scale was the only scale used to determine the internal validity of the included studies. More so, we included studies that utilized ODI and VAS/NPRS scale. Another limitation is that CS training, lumbar stabilization exercise, segmental stabilization exercises, and core stabilization exercises were used interchangeably in this review as poor distinction of these terms may affect the quality of this evidence.
| Conclusion|| |
The results of this review support the application of CSEs and stretching exercises in the management of pain and disability among CLBP patients as both were found to be effective, however, with none being more beneficial than the other. This was shown by all the three studies that were systematically reviewed. However, none of the three studies carried out follow-up assessment. Although this review may not be comprehensive about CSEs and stretching exercises and CLBP, it demonstrates a deep understanding of the use of CS and stretching exercises in the management of CLBP.
Implications for research
Articles that are methodologically sound and sufficiently powered are required to confirm the effects of CSE and stretching exercises on pain relief and functional improvements in patients with chronic LBP. More so, the effects of CSE and stretching exercises should be evaluated over a period of time postintervention.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, et al.
Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006;15 Suppl 2:S192-300.
Morris LD, Daniels K.J, Ganguli B, Louw QA. An update on the prevalence of low back pain in Africa: A systematic review and meta-analyses. BMC Musculoskelet Disord 2018;19:196.
Hartvigsen J, Hancock MJ, Kongsted A., Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention on behalf of the Lancet Low Back Pain Series Working Group. The Lancet (2018); 391(10137):2356-2367.
GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1789-858.
Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J 2010;10:514-29.
Delitto A, George SZ, van Dillen LR. Low back pain. J Orthop Sports Phys Ther 2012;42:A1-57.
Bae HI, Kim DY, Sung YH. Effects of a static stretch using a load on low back pain patients with shortened tensor fascia lata. J Exerc Rehabil 2017;13:227-31.
Suh JH, Kim H, Jung GP, Ko JY, Ryu JS. The effect of lumbar stabilization and walking exercises on chronic low back pain: A randomized controlled trial. Medicine (Baltimore) 2019;98:e16173.
Akhtar MW, Karimi H, Gilani SA. Effectiveness of core stabilization exercises and routine exercise therapy in management of pain in chronic non-specific low back pain: A randomized controlled clinical trial. Pak J Med Sci 2017;33:1002-6.
Collins JA, Fauser BC. Balancing the strengths of systematic and narrative reviews. Hum Reprod Update 2005;11:103-4.
Leite T, de Souza Teixeira A, Saavedra F, Leite RD, Rhea MR, Simão R. Influence of strength and flexibility training, combined or isolated, on strength and flexibility gains. J Strength Cond Res 2015;29:1083-8.
França FR, Burke TN, Caffaro RR, Ramos LA, Marques AP. Effects of muscular stretching and segmental stabilization on functional disability and pain in patients with chronic low back pain: A randomized, controlled trial. J Manipulative Physiol Ther 2012;35:279-85.
Bolarinde SO, Adegoke BO, Ayanniyi O, Olagbegi OM. Effects of stretching exercises on pain and functional disability in quarry workers with work-related low back pain. J Health Saf Res Pract 2017;9:3-11.
Chan ME, Adnan R, Azmi R. Effectiveness of core stability training and dynamic stretching in rehabilitation of chronic low back pain patients. Malays J Mov Health Exerc 2019;8:1-13.
Altman DG. Better reporting of randomised controlled trials: The CONSORT statement. BMJ 1996;313:570-1.
Moncur R, Larmer J. Clinical applicability of intention-to-treat analyses. Evid Based Med 2009;6:39-41.
Gupta SK. Intention-to-treat concept: A review. Perspect Clin Res 2011;2:109-12.
] [Full text]
Suresh K. An overview of randomization techniques: An unbiased assessment of outcome in clinical research. J Hum Reprod Sci 2011;4:8-11.
] [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]