the effect of hip muscle strengthening on pain and...

CRICOS No. 00213J a university for the world real R

School of Exercise & Nutrition Sciences

The effect of hip muscle strengthening on

pain and disability for individuals with non-

specific low back pain: an outcome based

randomised controlled trial

Karen D. Kendall, PhD, AEP, CEP, CSCS, CAT(C)

Carolyn A Emery, PhD

Preston J Wiley, MPE, MD

Reed Ferber, PhD, CAT(C), ATC



Exercise Therapy & Non-specific low back pain

Clinical practice guidelines support the use of exercise

therapy as a treatment for chronic low back pain (Koes, van

Tulder, Lin, Macedo, McAuley, & Maher C, 2010)

Motor control based lumbopelvic exercise programs are

commonly used in clinical practice

Motor control exercise is more effective than minimal

treatment but no more effective than manual therapy or other

forms of exercise therapy (Macedo et al, 2009)



Exercise Therapy and LOW BACK PAIN

RQ: How can we improve exercise therapy programs for

NSLBP patients?

Links between hip muscle performance and low back pain

have been shown (Nourbakhsh, & Arab 2002; Nadler et al 2002; Kendall et

al 2010)

RQ : Will the addition of hip strengthening exercise to

standard lumbopelvic exercise programs for NSLBP patients

result in improved lumbopelvic stability and decreased pain

and disability?

Methods: Analysis

BASELINE

• Pain

• Disability

• Bilateral Hip Strength X4

• Biomechanics

• Trendelenburg Test

• Walking

3 WEEK

• Pain

• Disability

POST TEST

• Pain

• Disability

• Bilateral Hip Strength X4

• Biomechanics

• Trendelenburg Test

• Walking

Outcome Variables:

Change in Pain (100m VAS Scale)

Change in Disability (Oswestry Disability Index V2)

Hip Strength (N/kg – Force dynamometry)

Biomechanics (Frontal plane motion analysis – Trunk, pelvis, hip)



Methods: Exercise Programs

Group One: Motor Control-

Focused Lumbopelvic Exercises

Group Two: Combined Motor

Control-Focused Lumbopelvic &

Hip Exercises

Focus:

Activation and re-training

of the deep muscles of

the trunk and pelvis

Focus:

Activation and re-training

of the deep muscles of

the trunk and pelvis

Strengthening of the

musculature that

supports the hip and

pelvis



Methods: Real-time Ultrasound Imaging



Main Results: Proportion of Successful Treatments

Group One

Minimal Clinical Important

Changes in Pain

60% Success


Changes in Disability

45% Success

Group Two


Changes in Pain

68% Success


Changes in Disability

43% Success

7



Main Results: Change in Pain Intensity

Lumbopelvic Exercises

Lumbopelvic + Hip Exercises

0 = No Pain 10 = Worst Pain

36%

46%

Change = 21mm

(+5mm, -58mm)

Change = 25mm

(+11mm, -71mm)

Mean Difference

between

Groups

4mm

Group One

Group Two



Main Results: Change in Disability

0

10

20

30

40

50

60

70

80

90

100

Group One Group Two

Baseline Post Test

Mild

to

M

odera

te

to

Severe

Dis

abili

ty

Change

Score

Osw

estr

y D

isabili

ty I

ndex %

Lumbopelvic Exercises Lumbopelvic + Hip Exercises

36% 40%

Change = -8%

(-24%, 2%)

Change = -8%

(-24%, 2%)



Secondary Results: Hip Strength & Mechanics

Group One

No significant changes in

hip strength


frontal plane mechanics

Group Two

Significant increases in hip

strength (HE, HIR, HER)


frontal plane mechanics

10



Conclusion

Combined program was no better than standard

lumbopelvic exercise program

Both programs resulted in clinically important reductions

in pain

Despite reductions in pain and increases in hip strength no

significant changes in frontal plane mechanics were

observed



First study to specifically investigate the effect of targeted

hip strengthening for NSLBP

Results do not preclude the use of hip strengthening for

individuals with NSLBP

Need for further research to identify optimal exercise

therapy interventions and better ways to quantify and

measure lumbopelvic stability

Clinical Implications



References

Kendall, K.D., Schmidt, C. & Ferber, R. (2010). The relationship between hip-abductor strength

and the magnitude of pelvic drop in patient with low back pain. Journal of Sport Rehabilitation,

19, 422-435.

Koes, B.W., van Tulder, M., Lin, C.W.C., Macedo, L.G., McAuley, J. & Maher, C. (2010). An

updated overview of clinical guidelines for the management of non-specific low back pain in

primary care. European Spine Journal, 19(12), 2075-2094.

Macedo, L.G., Maher, C.G. & McAuley, J.H. (2009). Motor control exercise for persistent, non-

specific low back pain: a systematic review. Physical Therapy, 89(1), 9-25.

Nadler, S., Malanga, G., DePrince, M., Stitik, T.P. & Feinberg J.H. (2000). The relationship

between lower extremity injury, low back pain, and hip muscle strength in male and female

athletes. Clinical Journal of Sport Medicine, 10, 89-97.

Nourbakhsh, M.R. & Arab, A.M. (2002). Relationship between mechanical factors an incidence

of low back pain. Journal of Orthopaedic & Sports Physical Therapy, 32(9), 447-460.



[email protected]

What a difference a year can make…..

March 2012

Kananaskis Provincial Park Alberta,

Canada

October 2013

Girraween National Park Queensland-

NSW border, Australia



Participant Flow Diagram



Results: NSLBP Patient Demographics

Group One

(n = 40)

Group Two

(n = 40)

Sex (female), n (%) 18 (45) 24 (60)

Age (years), (95%CI) 33 (33,41) 41 (37,45)

Height (cm), (95%CI) 172 (169,175) 170 (167,173)

Weight kg, (95%CI) 73 (68,78) 77 (71,83)

Time since onset of pain (years) (95%CI) 4 (3,6) 7 (4,10)

Type of pain (first episode) n (%) 7 (18) 3 (7)

Tampa Scale Total Score (units), (95%CI) 36 (35,38) 35 (33,37)

Pain intensity (mm), (95%CI) 57 (54,61) 55 (51,58)

Disability (%), (95%CI) 22 (19, 24) 20 (17,23)

Baseline Characteristics



Methods: Exercise Intervention

Lumbopelvic program

Static Control Static Control + movement Control during functional movement



Methods: Exercise Intervention

Lumboplevic + Hip exercise program

Hip Abduction

Hip Extension

Hip Internal Rotation

Hip External Rotation



Biomechanical Analysis: Marker Step Up



Biomechanical Outcome Measures

Trendelenburg Test

Trunk Position (Lean)

0° = vertical trunk = no lean

+ve number = left lean

-ve number = right lean

Pelvic Position (Drop)

0° = horizontal pelvis = level pelvis

+ve number = right pelvis is higher than the left

-ve number = left pelvis is higher than the right

Hip Position (Adduction)

+ve number = hip adduction

-ve number = hip abduction

Average peak angle during the last

5 seconds of the 30 second test

20



Results: Biomechanics Trendelenburg Test

Biomechanical

Measure

Group One

Standard Lumbopelvic

Exercise

Group Two

Combined Lumbopelvic + Hip

Exercise

Baseline

(n=35)*

(95%CI)

6Week FU

(n=31)*

(95%CI)

median (IQR)

Change

(n=32)*

(95%CI)

median (IQR)

Baseline

(n=39)*

(95%CI)

6Week FU

(n=34)*

(95%CI)

median (IQR)

Change

(n=34)*

(95%CI)

median (IQR)

TT Right

Pelvic Drop (°) -0.6(-1.8,0.6) a -0.7(-3.2,1.1) a -0.5(-1.7, 0.6) -0.6(-0.6,0.5) a -0.4(-2.5,1.2) a -0.2(-1.7,0.4)

Trunk Lean (°) -2.3(-3.6,0.9) b -1.3(-2.6,0.1) b 1.1(0.2,2.2) -2.1(-3.6,- 0.6) b -1.6(-3.2,0) b 0.3(-0.9,1.4)

Hip

Adduction(°)

-9.2(-10.5,-8.0) -8.6(-10.0,-7.8) 0.4(-0.6,1.4) -9.0(-10.1,-7.9) -8.6(-9.6,-7.5) 0.5(-0.5,1.5)

TT Left

Pelvic Drop (°) 0.8(-0.3,1.8) a 1.0(-0.2,2.1) a 0.2(-0.7,1.0) 2.4(1.2,3.6) a 2.0(-0.9,3.1) a 0.4(-1.3,0.5)

Trunk Lean(°)

2.0(0.5,3.5) b 1.2(-0.3,2.7) b -0.4(-0.9,1.1) 0.5(-0.9,1.8) b 0.1(-1.1,1.2) b -0.9(-2.0,0.2)

Hip

Adduction(°)

-9.1(-10.1,-8.0) -8.9(-10.0,-7.8) 0.1(-0.9,1.0) -6.9(-8.3,-5.6) -7.6(-8.9,-6.2) 0.7(-1.7,0.2)



Biomechanical Outcome Measures

Walking

Trunk and Pelvis Excursion

Sum of the maximum peak angles

during right and left stance phases

Right and Left Hip Excursion

Difference between the peak angle

at heel strike and the maximum peak

angle of hip adduction during stance

22

Averaged over 10 consecutive

steps



Results: Biomechanics Walking

Biomechanic

al Measure

Group One

Standard Lumbopelvic

Exercise

Group Two

Combined Lumbopelvic + Hip

Exercise

Baseline

(n=35)*

(95%CI)

6Week FU

(n=31)*

(95%CI)

median (IQR)

Change

(n=32)*

(95%CI)

median (IQR)

Baseline

(n=39)*

(95%CI)

6Week FU

(n=34)*

(95%CI)

median (IQR)

Change

(n=34)*

(95%CI)

median (IQR)

Pelvic

Excursion(°)

10.5(9.6,11.3) 9.9 (9.2,10.6) -0.5(-1.2,0.1) 9.9(8.9,10.8) 9.7(8.7,10.7) -0.1(-0.6,0.5)

Trunk

Excursion(°)

12.2(11.5,12.9) 11.8(9.6,13.0) -0.6(-1.3,0) 11.1(10.3,11.9) 10.5(8.5,12.9) -0.3(-0.9,0.3)

Right Hip

Excursion(°)

11.8(10.6,12.9)

11.5(10.5,12.5)

-0.2(-1.0,0.5)

11.2(10.0,12.4)

10.9(9.7,12.0)

-0.1(-0.7,0.4)

Left Hip

Excursion(°)

11.7(10.7,12.9)

11.6(10.6,12.5)

-0.3(-1.0,0.5)

10.7(9.6,11.9)

10.3(9.1,11.5)

-0.3(-0.9,0.4)

the effect of hip muscle strengthening on pain and...

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