Effects of proprioceptive exercises on pain and function in chronic neck- and low back pain rehabilitation: a systematic literature review

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Abstract

Background

Proprioceptive training (PrT) is popularly applied as preventive or rehabilitative exercise method in various sports and rehabilitation settings. Its effect on pain and function is only poorly evaluated. The aim of this systematic review was to summarise and analyse the existing data on the effects of PrT on pain alleviation and functional restoration in patients with chronic (≥3 months) neck- or back pain.

Methods

Relevant electronic databases were searched from their respective inception to February 2014. Randomised controlled trials comparing PrT with conventional therapies or inactive controls in patients with neck- or low back pain were included. Two review authors independently screened articles and assessed risk of bias (RoB). Data extraction was performed by the first author and crosschecked by a second author. Quality of findings was assessed and rated according to GRADE guidelines. Pain and functional status outcomes were extracted and synthesised qualitatively and quantitatively.

Results

In total, 18 studies involving 1380 subjects described interventions related to PrT (years 1994–2013). 6 studies focussed on neck-, 12 on low back pain. Three main directions of PrT were identified: Discriminatory perceptive exercises with somatosensory stimuli to the back (pPrT, n = 2), multimodal exercises on labile surfaces (mPrT, n = 13), or joint repositioning exercise with head-eye coordination (rPrT, n = 3). Comparators entailed usual care, home based training, educational therapy, strengthening, stretching and endurance training, or inactive controls. Quality of studies was low and RoB was deemed moderate to high with a high prevalence of unclear sequence generation and group allocation (>60%). Low quality evidence suggests PrT may be more effective than not intervening at all. Low quality evidence suggests that PrT is no more effective than conventional physiotherapy. Low quality evidence suggests PrT is inferior to educational and behavioural approaches.

Conclusions

There are few relevant good quality studies on proprioceptive exercises. A descriptive summary of the evidence suggests that there is no consistent benefit in adding PrT to neck- and low back pain rehabilitation and functional restoration.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-382) contains supplementary material, which is available to authorized users.

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Most cited references 82

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Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials.

K Schulz, I. Chalmers, R Hayes … (1995)

To determine if inadequate approaches to randomized controlled trial design and execution are associated with evidence of bias in estimating treatment effects. An observational study in which we assessed the methodological quality of 250 controlled trials from 33 meta-analyses and then analyzed, using multiple logistic regression models, the associations between those assessments and estimated treatment effects. Meta-analyses from the Cochrane Pregnancy and Childbirth Database. The associations between estimates of treatment effects and inadequate allocation concealment, exclusions after randomization, and lack of double-blinding. Compared with trials in which authors reported adequately concealed treatment allocation, trials in which concealment was either inadequate or unclear (did not report or incompletely reported a concealment approach) yielded larger estimates of treatment effects (P < .001). Odds ratios were exaggerated by 41% for inadequately concealed trials and by 30% for unclearly concealed trials (adjusted for other aspects of quality). Trials in which participants had been excluded after randomization did not yield larger estimates of effects, but that lack of association may be due to incomplete reporting. Trials that were not double-blind also yielded larger estimates of effects (P = .01), with odds ratios being exaggerated by 17%. This study provides empirical evidence that inadequate methodological approaches in controlled trials, particularly those representing poor allocation concealment, are associated with bias. Readers of trial reports should be wary of these pitfalls, and investigators must improve their design, execution, and reporting of trials.

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Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis.

P Hodges, C A Richardson (1996)

The contribution of transversus abdominis to spinal stabilization was evaluated indirectly in people with and without low back pain using an experimental model identifying the coordination of trunk muscles in response to a disturbances to the spine produced by arm movement. To evaluate the temporal sequence of trunk muscle activity associated with arm movement, and to determine if dysfunction of this parameter was present in patients with low back pain. Few studies have evaluated the motor control of trunk muscles or the potential for dysfunction of this system in patients with low back pain. Evaluation of the response of trunk muscles to limb movement provides a suitable model to evaluate this system. Recent evidence indicates that this evaluation should include transversus abdominis. While standing, 15 patients with low back pain and 15 matched control subjects performed rapid shoulder flexion, abduction, and extension in response to a visual stimulus. Electromyographic activity of the abdominal muscles, lumbar multifidus, and the surface electrodes. Movement in each direction resulted in contraction of trunk muscles before or shortly after the deltoid in control subjects. The transversus abdominis was invariably the first muscle active and was not influenced by movement direction, supporting the hypothesized role of this muscle in spinal stiffness generation. Contraction of transversus abdominis was significantly delayed in patients with low back pain with all movements. Isolated differences were noted in the other muscles. The delayed onset of contraction of transversus abdominis indicates a deficit of motor control and is hypothesized to result in inefficient muscular stabilization of the spine.

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A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction.

Manohar M Panjabi (2006)

Clinical reports and research studies have documented the behavior of chronic low back and neck pain patients. A few hypotheses have attempted to explain these varied clinical and research findings. A new hypothesis, based upon the concept that subfailure injuries of ligaments (spinal ligaments, disc annulus and facet capsules) may cause chronic back pain due to muscle control dysfunction, is presented. The hypothesis has the following sequential steps. Single trauma or cumulative microtrauma causes subfailure injuries of the ligaments and embedded mechanoreceptors. The injured mechanoreceptors generate corrupted transducer signals, which lead to corrupted muscle response pattern produced by the neuromuscular control unit. Muscle coordination and individual muscle force characteristics, i.e. onset, magnitude, and shut-off, are disrupted. This results in abnormal stresses and strains in the ligaments, mechanoreceptors and muscles, and excessive loading of the facet joints. Due to inherently poor healing of spinal ligaments, accelerated degeneration of disc and facet joints may occur. The abnormal conditions may persist, and, over time, may lead to chronic back pain via inflammation of neural tissues. The hypothesis explains many of the clinical observations and research findings about the back pain patients. The hypothesis may help in a better understanding of chronic low back and neck pain patients, and in improved clinical management.

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Author and article information

Contributors

Michael A McCaskey: m.mccaskey@reha-rhf.ch

Corina Schuster-Amft: c.schuster@reha-rhf.ch

Brigitte Wirth: brigitte.wirth@hest.ethz.ch

Zorica Suica: z.suica@reha-rhf.ch

Eling D de Bruin: eling.debruin@hest.ethz.ch

Journal

Journal ID (nlm-ta): BMC Musculoskelet Disord

Journal ID (iso-abbrev): BMC Musculoskelet Disord

Title: BMC Musculoskeletal Disorders

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2474

Publication date (Electronic): 19 November 2014

Publication date PMC-release: 19 November 2014

Publication date Collection: 2014

Volume: 15

Issue: 1

Electronic Location Identifier: 382

Affiliations

[ ]Research Department, Reha Rheinfelden, Salinenstrasse 98, 4310 Rheinfelden, Switzerland

[ ]Department of Health Sciences and Technology, ETH Zurich, Wolfgang-Pauli Str. 27, 8093 Zurich, Switzerland

[ ]Department of Epidemiology, CAPHRI School for Public Health and Primary Care, Maastricht University, PO Box 616, 6200 Maastricht, MD The Netherlands

[ ]Centre for Evidence Based Physiotherapy, Maastricht University, PO Box 616, 6200 Maastricht, MD The Netherlands

[ ]Institute of Rehabilitation and performance Technology, Bern University of Applied Sciences, Pestalozzistrasse 20, 3400 Burgdorf, Switzerland

Article

Publisher ID: 2326

DOI: 10.1186/1471-2474-15-382

PMC ID: 4247630

PubMed ID: 25409985

SO-VID: 1836a735-d949-44d2-8692-321306121f45

License:

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 24 September 2014

Date accepted : 6 November 2014

Custom metadata

ScienceOpen disciplines: Orthopedics

Keywords: proprioception,low back pain,neck pain,proprioceptive training,systematic review

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ScienceOpen disciplines: Orthopedics

Keywords: proprioception, low back pain, neck pain, proprioceptive training, systematic review

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Effects of proprioceptive exercises on pain and function in chronic neck- and low back pain rehabilitation: a systematic literature review

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Abstract

Background

Methods

Results

Conclusions

Electronic supplementary material

Related collections

Orthopedics

Most cited references 82

Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials.

Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis.

A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction.

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Cited by 26

Most referenced authors 2,660