International Journal of Current Research and Review Research Article

DOI: http://dx.doi.org/10.31782/IJCRR.2021.132029

Effect of Lumbar Stabilisation Exercises using the

Stable and Unstable Surface on Pain, Disability and
IJCRR Electromyography (EMG) Activity in Chronic Low
Section: Healthcare
ISI Impact Factor
(2019-20): 1.628
Back Pain
IC Value (2019): 90.81
SJIF (2020) = 7.893
Sheema Saleem1, Moazzam Hussain Khan2
Copyright@IJCRR MPT Research Scholar, Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi, India; 2Assistant Professor,
1

Centre for Physiotherapy and Rehabilitation Sciences Jamia Millia Islamia, New Delhi, India.

ABSTRACT
Introduction: Non-specific low back pain is one of the common representations of musculoskeletal disorders which can be
widely seen all over the world. It is mainly due to the unbalanced and weak muscles of the core, which plays a vital role in main-
taining stability and mobility of the spine. Consequently causes recurrence of back pain with activities.
The objective of the study: The study was done to evaluate the effects of lumbar stabilisation exercise using stable and un-
stable surfaces on pain, disability and electromyographic activity of the Erector spine and transverse abdomen are muscle in
chronic low back pain patients (CLBP).
Methods: Twenty-four patients with chronic low back pain were recruited in the study based on inclusion and exclusion criteria.
They were randomly allocated into two groups i.e Group A (n=12) lumbar stabilization exercise (LSE) on a stable surface while
Group B (n=12) LSE on an unstable surface for 3 sessions per week for 6 weeks in both the groups. The pain was assessed
using the Numerous Pain Rating Scale (NPRS), functional disability using Modified Oswestry Disability Index (MODI) Scale and
Muscle recruitment pattern using Electromyography (EMG).
Result: Six weeks of interventions showed significant improvement in pain, functional disability and muscle activity of core mus-
cles in both groups (p <0.05). While comparing both groups, there was a significant improvement in pain and muscle activity of
the transverse abdominal muscle in Group B patients (p <0.05).
Conclusion: Lumbar stabilization exercises using Swiss balls as unstable surfaces is effective interventional therapy for the
alleviation of chronic low back pain and improving the muscle recruitment pattern in patients.
Key Words: Chronic low back pain, Functional Disability, Lumbar Stabilization exercise, Swiss Ball, Erector Spinae muscle, Trans-
verse Abdominis muscle

INTRODUCTION To provide stability of the lumbar spine, core muscles

strengthening and stabilization exercises are important, and
Mechanical low back pain refers to pain caused by abnormal Core muscles mainly consist of deep stabilizer muscles are
stress and strain on vertebral column muscles which can be due transverse abdominis, multifidus, pelvic floor muscles etc
to poor posture, ill-designed ergonomics or incorrect bending and global muscles are erector spinae, rectus abdominis,
and lifting motions. It is the common representative muscular latissimus dorsi etc.5Core training emphasis strengthening
disorder and consists of spinal instability which further can and reconditioning of local and global muscles that work
lead to malfunctioning neuromuscular control.1Chronic low together to stabilize the spine.6 The local muscles are slow-
back pain (CLBP) is normally continuous back pain lasting twitch fibres while global muscles are torque producing
more than 3 months.2It is widely seen in 70-85% of the popu- muscles. The inter-segmental local muscle groups provide
lation with up to 80% of patients described at least one episode stabilization and control over supine position with lower
in their life.3According to the world health organization low force production.7
back pain constituted 37% of all occupational hazards which
occupy the first rank among all the diseases.4

Corresponding Author:
Dr. Moazzam Hussain Khan, Assistant Professor, Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi 110025,
India; Email: [email protected]
ISSN: 2231-2196 (Print) ISSN: 0975-5241 (Online)
Received: 28.01.2021 Revised: 03.03.2021 Accepted: 27.04.2021 Published: 24.10.2021

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 Saleem et al: Effect of lumbar stabilisation exercises using the stable and unstable surface on pain, disability and electromyography

The major problem is the weakness, lack of motor control Inclusion Criteria
and delayed speed of muscles contraction of deep trunk mus- Non-specific low back pain experienced at least from last 3
cles such as multifidus and Transverse Abdominis muscles.8 months, age 18- 45 years, NPRS score from 3 to 6, MODI
Deep stabilizer muscles in chronic low back pain patients score from 20% to 60% (minimal disability to moderate
become weak and imbalanced leading to reduced proprio- disability), able to attend the hospital for treatment over 6
ceptive sense which further leads to stability problems in the weeks, Prone instability test positive, Extensor endurance
spine and recurrence of back pain.9Therefore to treat LPB, test positive, Aberrant movement pattern present.10
deep stabilizer muscles exercise is required to balance the
muscle control and counteract muscle atrophy. Unstable Exclusion criteria
training equipment, such as Swiss balls, tend to increase Patients who have infectious pathology or injury received
the difficulty of performing exercises using complete body- surgical interventions for their back pain or were awaiting
weight and resistance using free weights.10 Exercises done surgery, diagnosis of clinical depression or other specific
using Swiss balls employ all body regions and extensively psychiatric pathology, contradicted to do exercises.10
activities can be done in comparison with exercises done on
All the participants were advised to avoid any other treat-
fixed floors. Using balls for performing exercises therefore
ment interventions and they were recruited for a 6-week
can enhance the ability of dynamic balance, stability and the
training program.
flexibility of the spine and improve the sense of balance to
prevent injuries.11So exercises were done on a stable and Measures and Interventions
unstable surface to examine its effects and measures using Demographic data of subjects age (2.1346±4.475),
NPRS scale, MODI scale and surface EMG of core muscles. height (1.676±7.471.), weight (62.130±0.113) and BMI
Recently a study was done to see the correlation between (21.922±0.610) were taken along with the pre-test outcome
the effects of trunk stability and LBP It has been suggested measures which include pain level, functional disability and
that to stabilize the trunk, correlation of deep and superficial EMG of transverse abdominis and erector spinae. To meas-
muscles are needed as they are directly attached to the spine ure the pain, Numerical Pain Rating Scale (NPRS) was used
and stabilization exercises helps in improving the function with an 0-10 integral rating scale. Modified Oswestry Dis-
on of neuromuscular system and hence support as well pro- ability Index (MODI) was used to assess the functional dis-
tect the spine.12LSE also helps in maintaining the neutral po- ability in CLBP.14The coefficient of Cronbach’s alpha was
sition of the spine, which is best for unloading of the spine. 0.92 and test-retest correlation reliability was 0.93.10
But no study shows the effectiveness of LSE on stable and Surface EMG of erector spinae and transverse abdominis
unstable surfaces and their impact on global and local core were taken by attaching disposable bipolar electrodes with
muscle activation patterns in CLBP.13 a diameter of 1 cm attached parallel to muscle fibres. Skin
Therefore, the study aimed to determine effective treatment preparation was done before the experiment to reduce im-
protocol for chronic low back patients by performing LSE on pedance. Muscle activity of Transverse Abdominis was re-
the stable or unstable surface and to find out which exercise corded by attaching surface electrode 2 cm away from the
is best for reduction of pain, improving the core muscles ac- anterior superior iliac spine anteromedially while the activa-
tivities and decreasing the functioning disability in chronic tion pattern of the Erector spinae was recorded by attach-
low back pain. ing electrodes at 3 cm apart from the spinous process at the
lateral side.12Ground electrode was attached over the supe-
rior aspect of the iliac crest of the same side.15 Every second
MATERIALS AND METHODS time of the isometric phase of each exercise the root mean
square (RMS) of EMG amplitude was calculated and then
mean RMS obtained from three Maximum Voluntary Con-
Design
traction trials for each muscle was used to provide a basis
Pre-test and post-test experimental design.
for EMG amplitudes normalization of data obtained during
the experimental exercises (%MVC). The static phase of the
Participants and Procedure experimental exercise was analysed, using means of three
A total of 24 male and female subjects having chronic non- trials. The root means square (RMS) for the 3 repetitions of
specific low back pain were recruited based on inclusion TA and ES muscles were normalised using 100 (%MVC). 16
and exclusion criteria. Participants were informed about the
purpose, procedure and effects of the treatment before the Treatments
experiment and written consent was taken from them. Ethi- Participants are randomly assigned into two groups by us-
cal clearance was taken from Institutional Ethical Committee ing computer randomization Group A (n=12) and Group B
Jamia Millia Islamia. (n=12). In Group A patients performed Lumbar Stabilization

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 Saleem et al: Effect of lumbar stabilisation exercises using the stable and unstable surface on pain, disability and electromyography

exercises on a stable surface along with hot fomentation for Table 2: Comparison of post-test Criterion measures
10 min while Group B received hot packs for 10 min along between groups
with lumbar stabilization exercises on an unstable surface i.e Variables Group A Group B t-value p-value
Swiss ball. Equilibrium is maintained for 10 sec with a break Mean(SD) Mean(SD)
of 3 seconds between repetitions for 40 min a day. Exercise
NPRS 0.50(0.07) 0.00(0.00) 2.171 0.041*
protocol for both the groups was Back Bridging Exercise,
Prone on Elbow, Posterior Pelvic Tilt, Abdominal Crunches MODI 6.833(1.992) 6.83(1.585) 0.000 1.000
and abdominal hollowing. Patients were instructed to main- EMG-TA 0.307(0.141) 0.52(0.167) 3.433 0.002*
tain the final position for 10 sec then return to the initial po-
EMG-ES 0.901(0.665) 0.69(0.421) 0.925 0.365
sition.10
Before initiation of each exercise program patients were Analysis of data within groups
given detailed verbal commands and visual clues or illus- Paired t-test was used to distinguish the comparison between
trations of exercise to patients emphasizing the starting and outcome variables at the baseline and Post-test measures in
ending position. The selection of appropriate Swiss balls was Group A and Group B. There was a significant difference in
based on demographic data given earlier. Group B was ad- NPRS as pre mean of pain was 4.58(0.996) and post mean
vised that the hip region must be parallel to the floor and the was 0.50(0.07)* in Group A and Group B pre mean was
patient knee must maintain an angle of 90° while sitting on 4.75(1.138) and post mean was 0.00(0.00)*which shows the
the Swiss ball .17 significant reduction of pain after 6 weeks of intervention.
Duration of treatment: Both groups received treatment for 3 Similarly, there were significant reductions in MODI and
days a week × 6 weeks, 10 times/set, 3 sets .10 EMG shown in figures 1A, 1B, 1C.

Data analysis
Data were assessed by SPSS version 17.0.Shapiro -Wilk test
for the normality of the distribution scores. The demographic
characteristic and the baseline criterion measure were com-
pared between the two experimental groups at the study
evaluated by an independent t-test. Then a paired t-test was
applied to analyze the effect of intervention in two groups for
the measures of pain (NPRS), functional disability (MODI)
and muscle activation of TA and ES muscles using EMG.

RESULTS
Patients Demographic Figure 1A: MODI Pre and Post in Group A (stable group) and
To prove the homogeneity between the two groups contrast- B (unstable group) showing means and standard deviation.
ing baseline criterion measurement was done using an in-
dependent t-test. No significant difference seen in baseline
value of (p>0.05), Table 1

Table 1: Demographic data and Baseline Criterion

Measures
Variables Group-A Group-B t-value p-value
Mean(SD) Mean(SD)
Age 25.75(4.475) 26.58(2.610) 0.557 0.583
Height 1.68(0.113) 1.67(0.090) 0.300 0.767
Weight 61.00(7.471) 63.50(6.023) 0.902 0.377
BMI 21.92(2.610) 22.92(2.875) 0.892 0.382
NPRS 4.58(0.996) 4.75(1.138) 0.382 0.706
Figure 1B: MVC-EMG of TA Pre and Post in Group A (stable
MODI 32.50(8.273) 31.33(8.49) 0.341 0.737 group) and B (unstable group) showing means and standard
EMG-TA 0.165(0.108) 0.102(0.049) 1.849 0.078 deviation.
EMG-ES 0.901(0.665) 0.691(0.420) 1.099 0.283

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 Saleem et al: Effect of lumbar stabilisation exercises using the stable and unstable surface on pain, disability and electromyography

cle which provide stability to the spine. Therefore emphasis

should be on the stabilization exercises instead of strength-
ening of the muscle in low back patients.19Similarly trunk
stabilizers muscles are more likely activated by unstable
surfaces than stable which can be used in low back pain pa-
tients.20 There was a significant improvement in MODI in
both groups after six weeks of intervention. But there was
no significant difference between the two groups. A score
less than 20% indicates that functional disability was not re-
garded as a significant functional disability in the daily life
of patients .21
Figure 1C: MVC of ES Pre and Post in Group A (stable group) Muscle activity of local and global muscle was evaluated by
and B unstable group) showing means and standard deviation. EMG before and after six weeks of intervention and it has
been seen that the MVC value of Transverse Abdominis and
Analysis of data between the two groups Erector Spinae significantly improves in both groups. The
An independent t-test was used to compare post-test criterion activity of transverse abdominis showed significant improve-
measurement between Group-A and Group-B. A significant ment in Group B as compared to another group, while there
difference was seen between the groups in Pain (NPRS) and was no notable difference in MVIC value of Erector Spinae
EMG activity of transverse abdominal muscle but there was muscle. According to some research, good activation of the
no significant difference in Functional Disability (MODI) local muscles can lead to optimal stabilization of the lower
and EMG activity of Erector Spinae as shown in table 2. This back during basic stabilization exercise (O’Sullivan et al.,
reveals that lumbar stabilisation exercises done on Swiss 2000; Richardson et al., 2004).22,9,25 In the study (Escamilia
balls were effective in decreasing chronic pain and increas- et al.,2005) concluded that local muscles have a greater pro-
ing muscle activity patterns of local core muscles. prioceptive function and the exercise done on Swiss balls
stresses these muscles to a greater extent which lead to im-
provement in balance.23,24Similarly deep abdominal muscle
DISCUSSION plays a very important role in providing spinal stability than
Patients having non-specific mechanical low back pain show superficial abdominal muscles. Despite the local muscles
physical deconditioning of the core and manifests as mus- having short moment arms, which are deep and tonic mus-
cle atrophy, decreased muscle strength and endurance. The cles functioning as stabilizers of lumbar segments whereas
localised and unilateral cross-sectional area of core muscles superficial muscles are movement generating muscles that
was also reduced in these patients. Active rehabilitation of provide overall stability.2
trunk musculature reduced LBP symptoms, increased mus- Future studies can be done using resistance exercise using
cle strength, cross-sectional area and endurance.18In the cur- thera-band to provide resistance during LSE on both surfac-
rent study pain was evaluated by NPRS scale so that subjec- es. An activity related EMG can be integrated comprising
tive pain intensity of patients with CLBP before and after both the local and global muscle Limitations of the study
6 weeks of training can be assessed. The reason for the re- where long term follow up can be taken to determine the
duction of pain was due to unbalanced core muscles training reversibility of the result and the result cannot be generalized
which leads to deep muscles activation and improves neuro- to the whole population.
muscular control. Yoon et al 2013, reported that stabilization
exercises help in the reduction of pain by decreasing the sig-
nal delivered to the pain receptive tissues such as ligaments CONCLUSION
and joint capsules and further decrease the load on the lum-
The result of the study demonstrated that both stable and
bar vertebrae and enhance the function of the core stabilizer
unstable surfaces significantly improved pain, functional
muscles leads to trunk positional control 16, a result which is
disability and muscle activation pattern of the core mus-
similar with our study result. Lee et al., 2014, reported a sig-
cles. Whereas, exercises performed on unstable surfaces are
nificant reduction in pain in CLBP after training with Swiss
more effective as they help in achieving trunk stability and
Ball 12, a result that is consistent with our study. Along with
increasing the muscle activation pattern of transverse ab-
that our result also showed that pain intensity significantly
dominal muscle to a great extent than the exercises done on
decreases Group B than Group A which was due to increased
a stable surface.
co-contraction pattern and activation in local core muscles.
In this study, the Lumbar stabilization exercise helped in
increasing proprioception and co-contraction of core mus-

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 Saleem et al: Effect of lumbar stabilisation exercises using the stable and unstable surface on pain, disability and electromyography

ACKNOWLEDGEMENT 11. Escamilla RF, Lewis C, Bell D, Bramblet G, Daffron J, Lambert

S, et al,. Core muscle activation during Swiss ball and tradition-
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tion, clinic staff, director of the centre of physiotherapy and 40(5):265-76.
12. Lee CW, Hwangbo K, Lee IS. The effects of combination pat-
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