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original article nr 2020 10 4 740 751 lumbopelvic stabilization exercises and mckenzie method in low back pain due to disc protrusion a blind randomized clinical trial 1 2 2 ...

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               ORIGINAL ARTICLE                                                                                           Nr 2020;10 (4):740-751
                 Lumbopelvic Stabilization Exercises and McKenzie 
                 Method in Low Back Pain Due to Disc Protrusion:  
                 A Blind Randomized Clinical Trial
                                      1                                2                            2                                 2
                 M. B. Dohnert , C. Schwanck Borges , A. Steffen Evaldt , C. de Jesus Francisco ,  
                                        2                            2                        2                          2                     2
                 L. da Silva Dias , B. Chuaste Flores , G. Maciel Bello , R. Dimer da Luz , R. Boff Daitx
                 1
                    Research, Teaching and Extension Laboratory in Orthopedic Trauma Physiotherapy (LAPEFITO), Gurupi 
                    University (UnirG), Gurupi, Torres, Brazil
                 2   Lutheran University of Brazil, Torres, Rio Grande do Sul, Brazil
             CORRESPONDING AUTHOR:                           SUMMARY
             Marcelo Baptiista Dohnert                       Introduction. Disc Protrusion (DP) is a degenerative spinal disorder. Lumbar interver-
             Research, Teaching and Extension                tebral disc protrusion is one of the most common   orthopedic injuries, leading to low 
             Laboratory in Orthopedic Trauma                 back pain that radiates to the lower limbs. Physical exercise is the main element in the 
             Physiotherapy (LAPEFITO)                        conservative treatment of low back pain. 
                                                             Objective. Comparing the effects of the McKenzie method and core stabilization exer
             Department of Physiotherapy                                                                                                       -
             University of Gurupi - UnirG                    cises on the rehabilitation of patients with lumbar DP. 
             355 Joaquim Batista de Oliveira Street          Methods. We allocated sixty-nine patients with low back pain due to disc protrusion 
             77.403-170 Vila Alagoana                        to the Core Group (CG), the McKenzie Group (MG), or the Core + McKenzie Group 
             Gurupi/TO, Brazil                               (CMG). All groups underwent three interventions per week for four weeks, totaling 12 
             E-mail: mdohnert@hotmail.com                    sessions. We assessed pain intensity, hamstring flexibility, functional capacity, muscle 
                                                             strength, and lumbopelvic stability. 
             DOI:                                            Results. All intervention groups significantly reduced pain intensity and functional 
             10.32098/mltj.04.2020.22                        disability, besides improving posterior muscle chain flexibility, quality of life, trunk 
                                                             muscle strength, and lumbopelvic stability (p < 0.05). For functional capacity, assessed 
             LEVEL OF EVIDENCE: 1B                           through the SF-26 Questionnaire, as well as for posture holding time in the lumbopel-
                                                             vic stability tests, the CG and CMG significantly improved the results compared to the 
                                                             MG (p < 0.05). 
                                                             Conclusions. The results suggest that both exercise methods were efficient in reducing 
                                                             pain and improving function in patients with low back pain due to disc protrusion. 
                                                             However, the groups that used stabilization exercises showed better results in activat-
                                                             ing lumbopelvic stabilizing muscles.
                                                             KEY WORDS
                                                             Low back pain; intervertebral disc displacement; physical therapy modalities; exercise 
                                                             therapy; spine osteoarthritis.
             INTRODUCTION                                                        (5, 6). Lumbar radiculopathy may be the result of a lumbar 
             Low back pain is a major health problem, with enormous              disc protrusion or hernia that can irritate a sacral plexus 
             economic and social costs (1). Disc Protrusion (DP) is a            trunk, leading to intraneural inflammation (6). A protrud-
             degenerative spinal disorder (1). The degenerated disc has          ing or herniated degenerated disc can cause paresthesia and 
             focal or localized abnormalities on the disc margin (2, 3). This    weakness in the lower limbs, in addition to pain (6). In the 
             disorder relates to age, gender, prolonged workload, trauma,        worst cases, lumbar radiculopathy can be chronic, resulting 
             and pregnancy (4). Lumbar intervertebral disc protrusion is         in pain, disability, and substantial burden in the long run (6). 
             one of the most common orthopedic conditions, producing,            This condition leads to health-related socioeconomic conse-
             in many cases, low back pain that radiates to the lower limbs       quences that directly affect well-being and quality of life (5, 7).
             740
                                                                                    M. B. Dohnert, C. SChwanCk BorgeS, a. Steffen evalDt, et al.
             Degenerated protruding discs and narrow spinal canals  association, on the rehabilitation of patients with low back 
             are common conditions in the elderly (8). However, most             pain due to disc protrusion.
             subjects adapt perfectly well to the degenerative findings of 
             imaging tests, keeping in shape, and avoiding poor posture          METHODS
             (8). Physical activity is the main element in the prevention 
             and treatment of low back pain (9). It does not require             Blind randomized clinical trial conducted from August 
             expensive materials, therefore providing an accessible inter-       2017 to June 2019. The study was registered in the Brazil-
             vention in which the patient directly controls pain (9).            ian Clinical Trials Registry (REBEC) under the identifica-
             Spinal stabilization and the McKenzie approach are two              tion number RBR-5mcvt6. The study was approved by the 
             different interventions for the treatment and preven-               Committee of Ethics on Human Research of Universidade 
             tion of low back pain (9). The core stabilization program           Luterana do Brasil under the number 2, 152, 592 (21).
             emphasizes the training of specific deep or local stabiliz-
             ing muscles of the spine, keeping the lumbar region in a 
             neutral position during occupational and daily life activities      Sample calculation
             (10). The McKenzie method, also called Mechanical Diag-             We used pain intensity, measured by VAS, as the primary 
             nosis and Therapy (MDT) (8), emphasizes an examination/             outcome of the study. Based on the study by Hasanpour-De-
             treatment that incorporates repeated spinal movements  hkordi, Dehghani and Solati (11), we used a study power of 
             (10, 11). The patient’s response to these repeated move-            80%, a 95% Confidence Interval, and a sample size ratio 
             ments determines a classification and a preferred direc-            of 1:1:1 (Core; McKenzie; Core + McKenzie) to estimate 
             tion for therapeutic exercise (11-14). Postural correction          the number of participants for each intervention group. 
             and maintenance of normal lordosis are an integral part of          Believing that losses and refusals would be around 20%, we 
             the McKenzie program, and treatment programs general-               reached the final number of 23 participants for each study 
             ly emphasize the performance of repeated lumbar move-               group, totaling 69 participants.
             ments for the effective management of specific syndromes 
             (13). This method considers the patient’s symptomatic and 
             mechanical response to repeated movements and sustained             Sample randomization 
             postures for evaluation and treatment (8, 14). Therefore,           After the initial assessment, we randomized the eligible 
             it uses a directional preference to reduce or increase the          participants by using a list of random numbers provided by 
                                                                                               ®
             patient’s symptoms (12, 14).                                        the EPI-Info  software. We allocated a total of 69 patients 
             The spinal stabilization system, also called core system,           to the following groups: McKenzie Group (MG), which 
             is composed of the spinal column, which provides intrin-            performed only one McKenzie exercise protocol, Core 
             sic stability, muscles that provide dynamic stability, and a        Group (CG), to which we applied lumbopelvic stabiliza-
             neural control unit that evaluates and determines the stabil-       tion exercises, and Core + McKenzie Group (CMG), which 
             ity and coordination requirements of the muscle response            performed both protocols (figure 1).
             (8). The central stabilizing muscles, also called core muscles, 
             are categorized, according to their function, as glob-
             al muscles (rectus abdominis, spinal erectors, and external         Elegibility criteria
             obliquus abdominis) and local muscles (transversus abdomi-          The study included 69 patients of both genders, aged 
             nis and lumbar multifidus) (15). Global muscles participate         between 18 and 65 years, who had low back pain due to 
             in trunk movements, while local muscles play an important           disc protrusion. The participants should have complemen-
             role in stabilizing the core (15). The transversus abdominis        tary exams (magnetic resonance or computed tomogra-
             and the lumbar multifidus play important roles in the func-         phy) showing DP and/or herniated disc, and should not be 
             tional activities of the spine (15). Core stabilization exercis-    performing any other type of physiotherapeutic approach 
             es aim to activate central muscles, including the transversus       for low back pain at the time of the study. All participants 
             abdominis, lumbar multifidus, and paraspinal, abdominal,            signed the Informed Consent Form (ICF).
             diaphragmatic, and pelvic muscles. This provides spinal             We excluded from the study patients who had severe spinal 
             stability and prevents lumbopelvic injuries by controlling          pathologies (fractures, tumors, and inflammatory pathol-
             joint tension, strengthening muscles, increasing resistance,        ogies such as ankylosing spondylitis), who had previous-
             and correcting posture (7, 16-20).                                  ly undergone lumbar surgery, patients with severe cardio-
             The present study compares the effects of the McKenzie              vascular and cardiorespiratory disease, pregnant women, 
             method and core stabilization exercises, as well as their           patients who did not attend three consecutive or intermit-
             Muscles, Ligaments and Tendons Journal 2020;10 (4)
                                                                                                                                              741
             Core Exercises and McKenzie Method in Lumbar Disc Protrusion
                                                              Recruited for the 
                                                               study (N=104)
                                                                                          Excluded (n=18)
                                                                                          • Age over 65 years (n=2)
                                                                                          • Referral for surgery (n=2)
                                                                                          • No schedule availability (n=5)
                                                                                          • Without MRI or CT examination (n=8)
                                                                                          • Performing another type of physical 
                                                                                          therapy approach (n=1)
                                                                Randomised 
                                                                   (N=86)
                            Allocated to the                                                     Allocated to the 
                              MG (N=31)                                                           CMG (N=28)
                                                              Allocated to the 
                                                                 CG (N=27)
                              Interrupted                                                          Interrupted 
                           intervention (n=8)                                                   intervention (n=5)
                             * Withdrawal                        Interrupted                      * Withdrawal
                                                              intervention (n=4)
                                                                * Withdrawal
                           Analyzed (N=23)                    Analyzed (N=23)                   Analyzed (N=23)
             Figure 1. Flowchart – Recruitment and evaluation of patients with disc protrusion. 
             RM: MRI; CT: Computed Tomography; CG: Core Group; MG: McKenzie Group; CMG: Core + McKenzie Group.
             tent consultations, and those that presented some neuro-          Pain intensity assessment
             logical disorder that prevented them from performing the          We assessed pain intensity by using the Visual Analogue 
             proposed exercises.                                               Scale (VAS). In this scale, the evaluator asks the patient 
                                                                               about his/her pain level on a scale from zero to ten, where 
                                                                               zero means total absence of pain and ten the maximum 
             Data collection                                                   tolerable pain.
             The evaluation protocol was conducted by a blind evalua-
             tor, that is who did not know which group the participant         Quality of life assessment
             belonged to. The evaluation took place in two stages of the       We assessed quality of life by using the SF-36 Question-
             study: initially – prior to the randomization of the subjects,    naire. This instrument consists of 11 questions and 36 items 
             and at the end of the intervention protocol.                      that encompass eight domains represented by functional 
                                                                               capacity, physical aspects, pain, general health status, vital-
             Anthropometric assessment                                         ity, social aspects, emotional aspects, and mental health. 
             We calculated the Body Mass Index (BMI) by measuring              The application of this questionnaire takes place through 
             body height and weight.                                           the attribution of a score for each question, later trans-
                                                                                              Muscles, Ligaments and Tendons Journal 2020;10 (4)
             742
                                                                                M. B. Dohnert, C. SChwanCk BorgeS, a. Steffen evalDt, et al.
            formed into a scale from “0” to “100” per domain, where          Lumbopelvic stability assessment
            “0” corresponds to the worst quality of life and “100” the       To analyze lumbopelvic stability, we applied the Single Leg 
            best quality of life.                                            Squat Test (unilateral squat), the Runner Pose Test, the 
                                                                             Prone Instability Test, the Right and Left Lateral Bridge 
            Functional capacity assessment                                   Test, and the Sorenson Test (extensor endurance test).
            To quantify disability, we used the Roland-Morris Disabili-
            ty Questionnaire. This instrument consists of 24 items that 
            describe daily tasks that patients have difficulty performing    Intervention protocol
            due to low back pain. The questions have a dichotomous           The intervention protocol consisted of three interventions 
            answer (yes or no), and the result corresponds to the sum        per week for four weeks, with all study groups performing 
            of the yes answers. This result can vary between 0 and 24,       a total of 12 sessions. The service took place individually. 
            with zero corresponding to a person without complaints,          Each session lasted between 40 and 60 minutes. Initial-
            and the maximum value corresponding to a patient with            ly, all participants performed a 10-minute stationary bicy-
            very severe limitations. The greater the number of alterna-      cle warm-up. Afterwards, we performed the intervention 
            tives filled in, the greater the functional impairment. We       according to the randomized group. The intervention proto-
            instructed the individuals to complete the items that better     col was applied by a researcher previously trained and famil-
            described them on the day of application.                        iar with the protocol. The interventor controlled during the 
                                                                             sessions the technique of performing each exercise, as well 
            Hamstring flexibility assessment                                 as its intensity and duration in both intervention groups.
            We measured hamstring flexibility by using the Wells bench. 
            For performing this test, the patient seated with legs extend-   Intervention protocol for the McKenzie Group
            ed and feet supported on the device. Then, the individual        The intervention protocol for the MG consisted of three 
            should flex his/her trunk and hips the maximum possible,         sets of exercises with 10 repetitions each, with a 30-second 
            with hands superimposed and supported on the measuring           interval between sets. We maintained the exercises for five 
            tape installed on the upper part of the Wells bench. The         seconds initially, subsequently maintaining them for 10 
            evaluator asked the patient to stretch his/her hands as far as   seconds according to the patient’s performance. We defined 
            he/she could reach without bending the knees, thus obtain-       the treatment from the result of the evaluation performed 
            ing the maximum reach point.                                     prior to the randomization stage, and guided it according to 
                                                                             the preferred direction of movement, that is flexion, exten-
            Trunk extensor muscle strength assessment                        sion, or lateral displacement of the spine. We applied the 
            We assessed trunk extensor muscle strength by using  McKenzie protocol according to Garcia et al. (13) (table I).
                        ®
            the Crown  dorsal dynamometer. In this test, the patient 
            remained standing, with feet supported and parallel, knees       Intervention protocol for the Core Group
            extended, and the spine initially flexed. At the command         In the CG protocol, we developed the exercises accord-
            of the examiner, the patient extended the spine by holding       ing to the studies of Moon et al. (21), who used eight exer-
            the lever bar with his/her upper limbs for dynamometer           cises based on static postures, initially maintained for five 
            measurement.                                                     seconds. As the program evolved, the degree of difficulty 
            Table I. McKenzie group exercise protocol. 
             Exercise                                                              Number of repetitions
             Exercise 1. Flexion of the lower limbs on the bench press             3 sets with 10 repetitions
             Exercise 2. Bending the trunk while sitting on the chair              3 sets with 10 repetitions  
             Exercise 3. Standing trunk flexion                                    3 sets with 10 repetitions
             Exercise 4. Prone trunk extension                                     3 sets with 10 repetitions
             Exercise 5. Standing trunk extension                                  3 sets with 10 repetitions
             Exercise 6. Lateralization of the standing pelvis                     3 sets with 10 repetitions for each side
             Exercise 7. Lateralization of the pelvis against the wall             3 sets with 10 repetitions for each side
            Muscles, Ligaments and Tendons Journal 2020;10 (4)
                                                                                                                                       743
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...Original article nr lumbopelvic stabilization exercises and mckenzie method in low back pain due to disc protrusion a blind randomized clinical trial m b dohnert c schwanck borges steffen evaldt de jesus francisco l da silva dias chuaste flores g maciel bello r dimer luz boff daitx research teaching extension laboratory orthopedic trauma physiotherapy lapefito gurupi university unirg torres brazil lutheran of rio grande do sul corresponding author summary marcelo baptiista introduction dp is degenerative spinal disorder lumbar interver tebral one the most common injuries leading that radiates lower limbs physical exercise main element conservative treatment objective comparing effects core exer department cises on rehabilitation patients with joaquim batista oliveira street methods we allocated sixty nine vila alagoana group cg mg or cmg all groups underwent three interventions per week for four weeks totaling e mail mdohnert hotmail com sessions assessed intensity hamstring flexibilit...

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