Effect of lumbar stabilization exercise on disc herniation index, sacral angle, and functional improvement in patients with lumbar disc herniation (2024)

Abstract

[Purpose] This study aimed to examine the effects of pelvic movements on the backfunction of patients with lumbar disc herniation when lumbar stabilization exercise wasapplied to the patients, suggest an intervention method that can be used in futureclinical therapies. [Subjects and Methods] Thirty patients with lumbar disc herniationunderwent the intervention 30 minutes per day, three times per week for 4 weeks. Of them,15 patients were assigned to the balance center stabilization resistance exercise group(experimental group I) and the other 15 were assigned to the three-dimensionalstabilization exercise group (experimental group II). Before the intervention, discherniation index was measured using magnetic resonance imaging, sacral angle was measuredusing X-ray, and back function was measured using the KODI. Four weeks later, these threefactors were re-measured and analyzed. [Results] There was a significant pre- versuspost-intervention difference in disc herniation index, sacral angle, and KODI inexperimental group I and a significant difference in disc herniation index and KODI inexperimental group II, and each group of disc herniation index and sacral angle had asignificant difference. In experimental group I, each disc herniation index and sacralangle had a negative correlation. [Conclusion] The lumbar stabilization exercise, whichcontrols balance using pelvic movements, improves mobility and stability of the sacroiliacjoint; therefore, it increases pelvic and back movements. These kinds of movements notonly improved proprioception sense, they also had positive effects on lumbar disc functionrecovery.

INTRODUCTION

Back pain is one of the most common diseases in modern society since 60–80% of thepopulation has experienced it at least once in their lifetime1⁾. Among back pain diseases, lumbar disc herniation is the most commondisease2⁾, decreasing the normal lumbarcurve and creating muscular stiffness. It also causes sacroiliac joint instability since thefacet joints and ligament flava are degenerated as the pelvis is warped and the sacral angleof inclination is increased3^, 4⁾. It also causes constant back pain and nerve root injectionbetween the legs since it makes sitting properly difficult and warps the posture, andproblems occur in balance and walking because of the weakened muscles surrounding thespine3⁾. These symptoms become severe dueto disability of the disc function caused by the herniation, which makes it difficult tomaintain sitting or standing postures since it is not able to disperse the impact applied tothe back5^, 6⁾. Constant health care and functional recovery are needed since thesesymptoms can cause disease recurrence in the same area and herniation in other segments.Therefore, it is necessary to perform early ambulation, exercise, and training7^, 8⁾.

Exercise in particular aims to actively strengthen the multifidus muscles and transverseabdominis muscles, deep muscles of the back; hence, lumbar stability exercises are needed tostabilize the spine segments and vitalize the local muscles around the back9⁾. However, lumbar stability exercises aredifficult to perform in the acute phase when back pain is severe and do not address pelvisproblems such as sacral joint instability since they focus only on the local trunk muscles.To compensate for these deficiencies, exercises are performed by patients using equipmentthat can be used in early parts, which stimulates not only the deep muscles but also thewhole trunk muscles and creates trunk stability10^,11^,12⁾.

With this principle, the balance center stabilization resistance exercise (Fig. 1), which uses the pelvic movements on moving disc, and three-dimensional (3D)stabilization exercises (Fig. 2), which can exercise on diverse degree. However, it remains to be seen howaccompanying symmetrical pelvis movements through these types of quantitative exercisespositively affect one’s back. Therefore, this study aimed to examine the effects of pelvismovements on back function when the balance center stabilization resistance and 3Dstabilization exercises are applied to patients via the quantitative measurement of patientswith lumbar disc herniation and investigated the correlation between the effects; analyzethe effects of back stabilization through pelvis movements on disc herniation index, sacralangle, and KODI; and make recommendations about how to manage lumbar disc herniationpatients.

SUBJECTS AND METHODS

This study was conducted for about 6 weeks from April 14 to May 22, 2017 after receivingapproval from the Institutional Review Board of Sehan University (approval No. SH-IRB2017–03). A total of 30 patients aged 25–50 years who were diagnosed with lumbar discherniation (below the protrusion) and visited the medical institutions in Seoul wereincluded. The included patients had no other diseases such as spondylolisthesis, a surgicalhistory, and no other surgical diseases or neurological disorders; each was able to walkindependently without a walker; and each understood the purpose of the study andparticipated voluntarily (Table 1).

The diagnoses of the 30 patients were verified using magnetic resonance imaging (MRI),after which point they were randomly assigned to the perform the balance centerstabilization resistance exercise (experimental group I; n=15) (Fig. 1) or the 3D back stabilization exercise group (experimentalgroup II; n=15) (Fig. 2). The interventionconsisted of performing the prescribed exercise for 30 minutes three times a week for 4weeks. Before the intervention, herniation index was measured using MRI, sacral angle wasmeasured using standing right posture X-rays, and back function was measured using theKorean Oswestry Disability Index (KODI). After 4 weeks, these variables were re-examined andanalyzed.

The disc herniation index measurement consists of measurement of the disc andintervertebral foramen at the intercept of the axial direction13⁾. The sagittal distance of the herniated disc was recordedas the maximum anteroposterior disc height (AB), while length of the vertebral foramen wasthe maximum anteroposterior canal length (EF). The width of the herniated disc was measuredby drawing a line in the middle of the anteroposterior disc length (CD), while the width ofthe spinal canal was calculated at the same level (GH). The formula of the herniated discindex is as follows: [(AB × CD)/(EF × GH)] ×1,00014⁾.

Sacral angle is the angle formed by the line drawn along the bottom surface of the sacrumwith the horizontal line in the lateral lumbar spine view using PACS (Picture Archiving andCommunications System) after the X-ray were taken and the normal range of 40°3⁾.

The KODI has nine questions, each of which is scored at a maximum of 6 points. Thereliability of the Korean version of the back pain disability index is high (r=0.92). Theback pain disability index is evaluated as maximum 45 points; the higher the total score,the greater the degree of disability and the lower the functional performance15^, 16⁾.

The balance center stabilization resistance exercise was conducted in the patients forabout 15–30 minutes using programs consisting of exercise mixed with core and balance. Allparticipants controlled the handle checking out whether the proper force was deliveredthrough the monitor while exercising on the moving platform12^, 17⁾.

The 3D back stabilization exercise required patients to stand upright and contract thetransverse abdominis muscle, and tilted patients at each angles using Centaur after fixingpelvic and femoral and making chins be “Chin in.” The exercise was conducted with thepatients regulating the turning time, pausing time, and angles gradually and the exercisetime was varied at 15–30 minutes (3–5 sets)18⁾.

The normality of the general characteristics of the subjects both groups were tested byusing the Shapiro-Wilk test and paired t-test was used to compare the changes in each groupof disc herniation index, sacral angle, and KODI. Analysis of covariance was used to compareintergroup changes, while SPSS 20.0 for Windows was used to examine changes in herniatedindex, sacral angle, and KODI. In addition, to investigate the correlation between discherniation index, sacral angle, and KODI, Pearson correlation analysis was used at asignificance level of α=0.05.

RESULTS

No special variables related to the general characteristics of the subject were foundbetween the group, thus indicating normality (Table1). There were significant differences in changes of both groups in disc herniationindex and KODI (Table2); after application of the sacral angle experiment, there was asignificant difference in experimental group I only (Table 2). There were also significant differences in the comparison of changesbetween herniated index and sacral angle (Table2). Also, in experimental group I, only herniated index and sacral angle showed anegative correlation, and there was no correlation among herniated index, sacral angle, andback function in experimental group II (Table3).

DISCUSSION

Performing quantitative exercise through the exercise equipment, patients who have lumbardisc herniation are stabilized in various activities. This lumbar stabilization exercise isused in patients in clinics to retrain the proprioceptive senses of the tissues surroundingthe joints10^, 12^, 19⁾.

Letafatkar et al.19⁾ reported thatbalance center stabilization resistance exercise positively affects back function since backpain was reduced and proprioceptive sense, lumbar movement control, and quality of lifeincreased. There were some significant differences in each disc herniation index group andKODI group in this study. However, there was a significant difference only in theexperimental group I in sacral angle test. The reason for this is that the 3D stabilizationexercise can lead to functional improvement due to the improvement of stabilization since itis used by patients when their lower limbs and pelvises are fixed, but it led to differentresults from those of the balance center stabilization resistance exercise since couplemotion of pelvic and back were not occurred. Also, the improvement of disk herniation indexwas evident as inflammatory exudation was eliminated after increase of the spinal nerves andblood flow rate of the intervertebral foramen by light exercise20⁾ through quantitative movements applied to the patients inthe range without pain and shown through the increased diameter of the intervertebralforamen and the improved circulation around the discs.

Han et al.21⁾ reported that the lumbarstabilization exercise, which eases the mental effort, decreases spinal movements, andimproves pelvic tilt, had positive effects on body balance and decreased weight and gravityon the lumbosacral area. Couillandre et al.17⁾ reported that balance center stabilization resistance exerciseimproves coordination as well as the muscular strength of back and the legs and improvesposture as the center of pressure is upgraded. In this study, there was a significantintergroup difference in disc herniation index and sacral angle. The result of this is asfollows. The balance center stabilization resistance exercise that patients performed on themoving plate by balancing through pelvic movement improved pelvis tilts more than the 3Dstabilization exercise, which does not have a joint movement but creates changes inproprioceptive sense19⁾ and has positiveeffects on the sacroiliac joint. The conclusion of Kim et al.22⁾ also supports this study since they stated that the proprioceptivesense can be improved when the dynamic balance sense exercise was applied to the patientsusing tools such as exercise balls.

Chu et al.23⁾ analyzed the correlationbetween lumbar disc herniation and intercostal line height in 445 back pain patients. Theyconcluded that the iliolumbar ligament brings instability to the lumbosacral joint andincreases the spinning movement when the iliolumbar ligament loses its function, so itincreases the possibility of L5/S1 lumbar disc herniation24⁾. On the other hand, the iliolumbar ligament becomes short and thinand L4/L5 lumbar disc degeneration occurs more rapidly and becomes susceptible toherniation25⁾. In this study, there wasa negative correlation only in experimental group I as disc herniation index increased,decreasing the sacral angle. The reason for this is that a decreasing sacral angle increasesstability while decreasing mobility but improves stability and mobility at the same timethrough the pelvic movement. This result improves the stability of the sacroiliac joint andthe physiological effects of the areas surrounding the lumbar disc20⁾ since it results in functional improvement of the back byreducing stress on the spine and sacroiliac joint16⁾. Thus, this study demonstrated that the balance centerstabilization resistance exercise, which increases sacroiliac joint stability by controllingbalance through pelvic movements, can be clinically effective in patients with lumbar discherniation causing postural and spinal imbalances.

The limitation of this study is that it is difficult to generalize our findings to everylumbar disc herniation patient since it was conducted at one medical institution and it wasnot able to control confounding variables such as drugs taken by the patients.

Acknowledgments

This paper was supported by the Sehan University Research Fund in 2017.

REFERENCES