Comparison of yoga and dynamic neuromuscular stabilization exercise in chronic low back pain on magnetic resonance imaging of lumbar multifidus- protocol for a randomized controlled trial

Prem Venkatesan, Soundararajan K, Thomas J Kishen, Seema Janardhan, Sathish Kumar Cr, Prem Venkatesan, Soundararajan K, Thomas J Kishen, Seema Janardhan, Sathish Kumar Cr

Abstract

Background: Degeneration of Lumbar muscle in chronic low back pain (CLBP) is characterized by an increase in fat infiltration of paraspinal muscle, decrease in the cross-sectional area (CSA) of lumbar multifidus muscle (LMM) and increased thickness of Thoracolumbar fascia (TLF) by 25%. The study objective is to compare the effects of yoga and dynamic neuromuscular stabilization (DNS) exercise on CSA, fat infiltration of LMM with magnetic resonance imaging (MRI), and TLF thickness using musculoskeletal ultrasound imaging (MSK-USI) in CLBP.

Methods: One hundred and forty-four participants with CLBP, which persisted longer than three months, will be recruited for this trial. Both group interventions focused on LMM. The experimental group will receive structured yoga sessions, and the Control Group will receive exercise based on DNS. In each group, exercises will be performed for 3-5 days/week and progressed for 12 weeks. Baseline data will be collected, followed by the recording of primary outcome measure (MRI) and secondary outcome measures (MSK-USI, Oswestry disability index, visual analogue score, optimism, self-efficacy, mood, physical activity, fear of movement, pain catastrophizing, and coping) at baseline and the end of 12th weeks. The normality of data will be verified. Based on the data distribution, within-group analysis and between-group analysis will be performed.

Discussion: This will be the first RCT to compare the effect of yoga and DNS exercise among chronic low back pain participants. This will provide evidence of these interventions' impact on CSA, fat infiltration of LMM, and thickness of TLF in CLBP.

Registration number: CTRI/2021/08/035984 (This trial was registered prospectively).

Keywords: Chronic low back pain; Dynamic neuromuscular stabilization exercise; Multifidus; Thoracolumbar fascia; Yoga.

Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

© 2022 Published by Elsevier Inc.

Figures

Fig. 1
Fig. 1
Overview of trial design – CONSORT flow chart.
Fig. 2
Fig. 2
Screening form.
Fig. 3
Fig. 3
Randomization form.
Fig. 4
Fig. 4
Randomization sealed envelope.
Fig. 5
Fig. 5
Follow-up log form.

References

    1. Hayden J.A., van Tulder M.W., Malmivaara A., Koes B.W. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst. Rev. 2005 July 20;(3):CD000335. doi: 10.1002/14651858.CD000335.pub2.
    1. Bindra S., Sinha A.G., Benjamin A.I. Epidemiology of low back pain in Indian population: a review. Int J Basic Appl Med Sci. 2015;5:166–179.
    1. Hildebrandt M., Fankhauser G., Meichtry A., Luomajoki H. Correlation between lumbar dysfunction and fat infiltration in lumbar multifidus muscles in patients with low back pain. BMC Muscoskel. Disord. 2017;18(1) doi: 10.1186/s12891-016-1376-1.
    1. Sions J., Elliott J., Pohlig R., Hicks G. Trunk muscle characteristics of the multifidi, erector spinae, psoas, and quadratus lumborum in older adults with and without chronic low back pain. J. Orthop. Sports Phys. Ther. 2017;47(3):173–179. doi: 10.2519/jospt.2017.7002.
    1. Singh R., Yadav S., Sood S., Yadav R., Rohilla R. Magnetic resonance imaging of lumbar trunk parameters in chronic low backache patients and healthy population: a comparative study. Eur. Spine J. 2016;25(9):2864–2872. doi: 10.1007/s00586-016-4698-7.
    1. Hides J., Gilmore C., Stanton W., Bohlscheid E. Multifidus size and symmetry among chronic LBP and healthy asymptomatic subjects. Man. Ther. 2008;13:43–49. doi: 10.1016/j.math.2006.07.017.
    1. Chan S.T., Fung P.K., Ng N.Y., Ngan T.L., Chong M.Y., Tang C.N., He J.F., Zheng Y.P. Dynamic changes of elasticity, cross-sectional area, and fat infiltration of multifidus at different postures in men with chronic low back pain. Spine J. 2012;12:381–388. doi: 10.1016/j.spinee.2011.12.004.
    1. Barker K.L., Shamley D.R., Jackson D. Changes in the cross-sectional area of multifidus and psoas in patients with unilateral back pain: the relationship to pain and disability. Spine. 2004;29:E515–E519. doi: 10.1097/01.brs.0000144405.11661.eb.
    1. Lee S., Chan C.K., Lam T., Lam C., Lau N., Lau R.W., Chan S.T. Relationship between low back pain and lumbar multifidus size at different postures. Spine. 2006;31:2258–2262. doi: 10.1097/01.brs.0000232807.76033.33.
    1. Wallwork T.L., Stanton W.R., Freke M., Hides J. The effect of chronic low back pain on size and contraction of the lumbar multifidus muscle. Man. Ther. 2009;14:496–500. doi: 10.1016/j.math.2008.09.006.
    1. Mayer J., Graves J., Clark B., Formikell M., Ploutz-Snyder L. The use of magnetic resonance imaging to evaluate lumbar muscle activity during trunk extension exercise at varying intensities. Spine. 2005;30(22):2556–2563. doi: 10.1097/01.brs.0000186321.24370.4b.
    1. D'Hooge R., Cagnie B., Crombez G., Vanderstraeten G., Achten E., Danneels L. Lumbar muscle dysfunction during remission of unilateral recurrent non-specific low-back pain. Clin. J. Pain. 2012;29:187–194.
    1. Lee S., Chan C.K., Lam T., Lam C., Lau N., Lau R.W., et al. Relationship between low back pain and lumbar multifidus size at different postures. Spine. 2006;31:2258–2262. doi: 10.1097/01.brs.0000232807.76033.33.
    1. Goubert D., De Pauw R., Meeus M., Willems T., Cagnie B., Schouppe S., et al. Lumbar muscle structure and function in chronic versus recurrent low back pain: a cross-sectional study. Spine J. 2017 Sep;17(9):1285–1296. doi: 10.1016/j.spinee.2017.04.025.
    1. Imai A., Okubo Y., Kaneoka K. Evaluation of psoas major and quadratus lumborum recruitment using diffusion-weighted imaging before and after 5 trunk exercises. J. Orthop. Sports Phys. Ther. 2017;47(2):108–114. doi: 10.2519/jospt.2017.6730.
    1. Fortin M., Macedo L.G. Multifidus and paraspinal muscle group cross-sectional areas of patients with low back pain and control patients: a systematic review with a focus on blinding. Phys. Ther. 2013 doi: 10.2522/ptj.20120457.
    1. Goubert D., Oosterwijck J., Meeus M., Danneels L. Structural changes of lumbar muscles in non-specific low back pain. Pain Physician. 2016;19:E985–E1000. September/October 2016.
    1. Ranger T., Cicuttini F., Jensen T., Peiris W., Hussain S., Fairley J., et al. Are the size and composition of the paraspinal muscles associated with low back pain? A systematic review. Spine J. 2017;17(11):1729–1748. doi: 10.1016/j.spinee.2017.07.002.
    1. Yanagisawa O., Matsunaga N., Okubo Y., Kaneoka K. Noninvasive evaluation of trunk muscle recruitment after trunk exercises using diffusion-weighted MR imaging. Magn. Reson. Med. Sci. 2015;14(3):173–181. doi: 10.2463/mrms.2014-0073.
    1. De Ridder E.M., Van Oosterwijck J.O., Vleeming A., Vanderstraeten G.G., Danneels L.A. Muscle functional MRI analysis of trunk muscle recruitment during extension exercises in asymptomatic individuals. Scand. J. Med. Sci. Sports. 2015;25:196–204. doi: 10.1111/sms.12190.
    1. Levine J.D., Fields H.L., Basbaum A.I. Peptides and the primary afferent nociceptor. J. Neurosci. 1993;13(6):2273e2286. doi: 10.1523/JNEUROSCI.13-06-02273.1993. Jun. submitted for publication.
    1. Tesarz J., Hoheisel U., Wiedenhofer B., et al. Sensory innervation of the thoracolumbar fascia in rats and humans. Neuroscience. 2011;194:302e308. doi: 10.1016/j.neuroscience.2011.07.066.
    1. Bednar D.A., Orr F.W., Simon G.T. Observations on the pathomorphology of the thoracolumbar fascia in chronic mechanical back pain. A microscopic study. Spine. 1995;20:1161–1164. doi: 10.1097/00007632-199505150-00010.
    1. Langevin H.M., Stevens-Tuttle D., Fox J.R., Badger G.J., Bouffard N.A., Krag M.H., et al. Ultrasound evidence of altered lumbar connective tissue structure in human subjects with chronic low back pain. BMC Muscoskel. Disord. 2009;10:151. doi: 10.1186/1471-2474-10-151.
    1. Cramer H., Lauche R., Dobos G. Characteristics of randomized controlled trials of Yoga: a bibliometric analysis. BMC Compl. Alternative Med. 2014;14:328. doi: 10.1186/1472-6882-14-328. authors.
    1. Patil N.J., Nagarathna R., Tekur P., Patil D.N., Nagendra H.R., Subramanya P. Designing, validation, and feasibility of integrated yoga therapy module for chronic low back pain. Int. J. Yoga. 2015 Jul-Dec;8(2):103–108. doi: 10.4103/0973-6131.158470.
    1. Frank C., Kobesova A., Kolar P. Dynamic neuromuscular stabilization & sports rehabilitation. The International Journal of Sports Physical Therapy. 2013;8:62. Number 1 February.
    1. Fisher M., Meyer R., Adams G., et al. Direct relationship between proton T2 and exercise intensity in skeletal muscle MR images. Invest. Radiol. 1990;25:480–485. doi: 10.1097/00004424-199005000-00003.
    1. Büssing A., Poier D., Ostermann T., Kröz M., Michalsen A. Treatment of chronic lower back pain: study protocol of a comparative effectiveness study on Yoga, eurythmy therapy, and physiotherapeutic exercises. Compl. Med. Res. 2018;25(1):24–29. doi: 10.1159/000471801.
    1. Cramer H., Lauche R., Dobos G. Characteristics of randomized controlled trials of Yoga: a bibliometric analysis. BMC Compl. Alternative Med. 2014;14:328. doi: 10.1186/1472-6882-14-328. authors.
    1. Patil N.J., Nagarathna R., Tekur P., Patil D.N., Nagendra H.R., Subramanya P. Designing, validation, and feasibility of integrated yoga therapy module for chronic low back pain. Int. J. Yoga. 2015 Jul-Dec;8(2):103–108. doi: 10.4103/0973-6131.158470.
    1. Qaseem A., Wilt T.J., McLean R.M., Forciea M.A. Non-invasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann. Intern. Med. 2017 April 4;166(7):514–530. doi: 10.7326/M16-2367.
    1. Kreiner D.S., Matz P., Bono C.M., Cho C.H., Easa J.E., Ghiselli G., Ghogawala Z., Reitman C.A., Resnick D.K., Watters W.C., 3rd, Annaswamy T.M., Baisden J., Bartynski W.S., Bess S., Brewer R.P., Cassidy R.C., Cheng D.S., Christie S.D., Chutkan N.B., Cohen B.A., Yahiro A.M. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. Spine J.: official journal of the North American Spine Society. 2020;20(7):998–1024. doi: 10.1016/j.spinee.2021.02.006.
    1. Zhu F., Zhang M., Wang D., Hong Q., Zeng C., Chen W. Yoga compared to non-exercise or physical therapy exercise on pain, disability, and quality of life for patients with chronic low back pain: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2020 Sep 1;15(9) doi: 10.1371/journal.pone.0238544.
    1. Wieland L.S., Skoetz N., Pilkington K., Vempati R., D'Adamo C.R., Berman B.M. Yoga treatment for chronic non‐specific low back pain. Cochrane Database Syst. Rev. 2017;(1) doi: 10.1002/14651858.CD010671.pub2.
    1. Park C., Yoon S., Yoon H., Kim K., Cha Y., Park I. Effects of core stabilization exercise on muscle activity during horizontal shoulder adduction with loads in healthy adults: a randomized controlled study. J. Mech. Med. Biol. 2021 Jul 30 doi: 10.1142/S0219519421400492.
    1. Bokarius V. Long-term efficacy of dynamic neuromuscular stabilization in treatment of chronic musculoskeletal pain. Age. 2008;18(25):3.
    1. Park I., Park C., Kim K., Cha Y. The effects of dynamic neuromuscular stability exercise on the scoliosis and pain control in the youth baseball players. J. Mech. Med. Biol. 2021 Aug 5
    2. Sharma K., Yadav A. Dynamic neuromuscular stabilization- a narrative review. Int. J. Health Sci. Res. 2020;10(9):221–231. doi: 10.1142/S0219519421400303.
    1. Lim Y.L., Lepsikova M., Singh D.K. Regional Conference on Science, Technology and Social Sciences (RCSTSS 2016) Springer; Singapore: 2018. Effects of dynamic neuromuscular stabilization on lumbar flexion kinematics and Posture among adults with chronic non-specific low back pain: a study protocol; pp. 715–724.
    1. Son M.S., Jung D.H., You J.S., Yi C.H., Jeon H.S., Cha Y.J. Effects of dynamic neuromuscular stabilization on diaphragm movement, postural control, balance and gait performance in cerebral palsy. NeuroRehabilitation. 2017 January 1;41(4):739–746. doi: 10.3233/NRE-172155.
    1. Yoon H.S., You J.S. Reflex-mediated dynamic neuromuscular stabilization in stroke patients: EMG processing and ultrasound imaging. Technol. Health Care. 2017 January 1;25(S1):99–106. doi: 10.3233/THC-171311.
    1. Novak J., Jacisko J., Busch A., Cerny P., Stribrny M., Kovari M., Podskalska P., Kolar P., Kobesova A. Intra-abdominal pressure correlates with abdominal wall tension during clinical evaluation tests. Clin. BioMech. 2021 Aug 1;88 doi: 10.1016/j.clinbiomech.2021.105426.
    1. Bae W.S., Lee K.C., Lee D.Y. The effects of dynamic neuromuscular stabilization exercise on forward head posture and spine posture. Med. Leg. Update. 2019 August 8;19(2):670–675. doi: 10.21203/-384623/v1.
    1. Kader D., Wardlaw D., Smith F. Correlation between the MRI changes in the lumbar multifidus muscles and leg pain. Clin. Radiol. 2000;55(2):145–149. doi: 10.1053/crad.1999.0340.
    1. Langevin H., Stevens-Tuttle D., Fox J., Badger G., Bouffard N., Krag M., et al. Ultrasound evidence of altered lumbar connective tissue structure in human subjects with chronic low back pain. BMC Muscoskel. Disord. 2009;10(1) doi: 10.1186/1471-2474-10-151.
    1. Boonstra A.M., Schiphorst P., Henrica R., Michiel F., Jitze B., Roy E. Reliability and validity of the Visual Analogue Scale for Disabilty in patients with chronic musculoskeletal pain. J. Int. Res. 2008;2:165–169. doi: 10.1097/MRR.0b013e3282fc0f93.
    1. Fairbank J.C., Pynsent P.B. The Oswestry disability index. Spine. 2000;25(22):2940–2952. doi: 10.1093/occmed/kqw051.
    1. Scheier M.F., Carver C.S., Bridges M. Distinguishing Optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a reevaluation of the Life Orientation Test. J. Pers. Soc. Psychol. 1994;67:1063–1078. doi: 10.1037//0022-3514.67.6.1063.
    1. Merriwether E.N., Rakel B.A., Zimmerman M.B., Dailey D.L., Vance C.G.T., Darghosian L., Golchha M., Geasland K.M., Chimenti R., Crofford L.J., et al. Reliability and construct validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) instruments in women with fibromyalgia. Pain Med. 2017;18(8):1485–1495. doi: 10.1186/s13075-018-1671-3.
    1. Sullivan M.J.L., Bishop S.R., Pivik J. The pain catastrophizing scale: development and validation. Psychol. Assess. 1995;7:524–532. doi: 10.1037/1040-3590.7.4.524.
    1. Roelofs J., Goubert L., Peters M.L., Vlaeyen J.W., Crombez G. The Tampa Scale for Kinesiophobia: further examination of psychometric properties in patients with chronic low back pain and fibromyalgia. Eur. J. Pain. 2004;8(5):495–502. doi: 10.1016/j.ejpain.2003.11.016.
    1. Watson D., Clark L.A., Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J. Pers. Soc. Psychol. 1988;54:1063–1070. doi: 10.1037//0022-3514.54.6.1063.
    1. Rosenstiel A., Keefe F.J. The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain. 1983;17:33–44. doi: 10.1016/0304-3959(83)90125-2.
    1. Anderson K.O., Dowds B.N., Pelletz R.E., Edwards W.T., Peeters- Asdourian C. Development and initial validation of a scale to measure self-efficacy beliefs in patients with chronic pain. Pain [Internet] 1995;63(1):77–84. doi: 10.1016/0304-3959(95)00021-J. [cited 2016 mar 31]
    1. Zgierska A.E., Burzinski C.A., Garland E.L., Lennon R.P., Jamison R., Nakamura Y., Barrett B., Sehgal N., Mirgain S.A., Singles J.M., Cowan P. Mindfulness-based therapy compared to cognitive behavioral therapy for opioid-treated chronic low back pain: protocol for a pragmatic randomized controlled trial. Contemp. Clin. Trials. 2021 Nov 1;110 doi: 10.1016/j.cct.2021.106548.
    1. Traeger A.C., Moseley G.L., Hübscher M., Lee H., Skinner I.W., Nicholas M.K., Henschke N., Refshauge K.M., Blyth F.M., Main C.J., Hush J.M. Pain education to prevent chronic low back pain: a study protocol for a randomised controlled trial. BMJ Open. 2014 May 1;4(6) doi: 10.1136/bmjopen-2014-005505.
    1. Delitto A., Patterson C.G., Stevans J.M., Brennan G.P., Wegener S.T., Morrisette D.C., Beneciuk J.M., Freel J.A., Minick K.I., Hunter S.J., Ephraim P.L. Study protocol for targeted interventions to prevent chronic low back pain in high-risk patients: a multi-site pragmatic cluster randomized controlled trial (TARGET Trial) Contemp. Clin. Trials. 2019 Jul 1;82:66–76. doi: 10.1016/j.cct.2019.05.010.
    1. Cavalcante P.G., Baptista A.F., Cardoso V.S., Filgueiras M.D., Hasue R.H., João S.M., Hazime F.A. Transcranial direct current stimulation combined with therapeutic exercise in chronic low back pain: protocol of a randomized controlled trial. Phys. Ther. 2020 Aug 31;100(9):1595–1602. doi: 10.1093/ptj/pzaa105.
    1. Iversen V.M., Vasseljen O., Mork P.J., Berthelsen I.R., Børke J.B., Berheussen G.F., Tveter A.T., Salvesen Ø., Fimland M.S. Resistance training in addition to multidisciplinary rehabilitation for patients with chronic pain in the low back: study protocol. Contemp. Clin. Trials Commun. 2017 Jun 1;6:115–121. doi: 10.1016/j.conctc.2017.04.001.
    1. D O'Halloran P., Holden J., Breckon J., Davidson M., Rahayu W., Monfries M., Taylor N.F. Embedded Motivational Interviewing combined with a smartphone app to increase physical activity in people with sub-acute low back pain: study protocol of a cluster randomised control trial. Contemp. Clin. Trials Commun. 2020 Mar 1;17 doi: 10.1016/j.conctc.2019.100511.
    1. Clark B.C., Russ D.W., Nakazawa M., France C.R., Walkowski S., Law T.D., Applegate M., Mahato N., Lietkam S., Odenthal J., Corcos D. A randomized control trial to determine the effectiveness and physiological effects of spinal manipulation and spinal mobilization compared to each other and a sham condition in patients with chronic low back pain: study protocol for the RELIEF Study. Contemp. Clin. Trials. 2018 Jul 1;70:41–52. doi: 10.1016/j.cct.2018.05.012.
    1. Groessl E.J., Schmalzl L., Maiya M., Liu L., Goodman D., Chang D.G., Wetherell J.L., Bormann J.E., Atkinson J.H., Baxi S. Yoga for veterans with chronic low back pain: Design and methods of a randomized clinical trial. Contemp. Clin. Trials. 2016 May 1;48:110–118. doi: 10.1016/j.cct.2016.04.006.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera