Combination of Electrical Stimulation and Motor Control Exercise for Chronic Nonspecific Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Research Article

Phys Med Rehabil Int. 2023; 10(3): 1220.

Combination of Electrical Stimulation and Motor Control Exercise for Chronic Nonspecific Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Xiaoyu G1#; Wuwei S2#; Huihui L3; Wenyu J1; Jiacheng Y1; Xiang W1*; Hongsheng Z1*

¹Shi’s Center of Orthopedics and Traumatology (Institute of Traumatology), Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, China

²Huamu Community Health Service Centre of Shanghai Pudong New District, China

³Department of Orthopedics and Traumatology, Chongming Branch of Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, China

*Corresponding author: Xiang W Shi’s Center of Orthopedics and Traumatology (Institute of Traumatology, Shuguang Hospital), Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, 185 Pu’an Road, Huangpu District, Shanghai 200021, China.

Hongsheng Z, Shi’s Center of Orthopedics and Traumatology (Institute of Traumatology, Shuguang Hospital), Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, 185 Pu’an Road, Huangpu District, Shanghai 200021, China. Email: w8x@163.com; zhanhongsheng@shutcm.edu.cn

#These authors contributed equally to this work.

Received: September 28, 2023 Accepted: October 26, 2023 Published: November 02, 2023 Phys Med

Abstract

Objective: To evaluate the efficacy of the combination of electrical stimulation and motor control exercise for chronic nonspecific low back pain compared to other treatments.

Data Sources: A systematic search was conducted in PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL) and the Cumulative Index to Nursing & Allied Health Literature (CINAHL) from the earliest record to 30 April 2022.

Methods: We included randomized controlled trials that investigated the effect of combination of electrical stimulation and motor control exercise compared to control groups for patients with chronic nonspecific low back pain. The meta-analysis is performed to compare the pain and disability outcome measures. The protocol for this systematic review was prospectively registered on PROSPERO (registration number: CRD42022324850).

Results: Ten articles enrolling 665 participants were included in the meta-analysis. The meta-analysis found low quality evidence (six studies) that the pain relief differed significantly between the combination of Electrical Stimulation with Motor Control Exercise (ES+MCE) and non-ES controls (sham, placebo or without ES) (Standardized Mean Difference (SMD)=-0.25, 95% Confidence Interval (CI) with lower and upper limits, -0.47 to -0.028, the p value (P)=0.028). For disability outcome, low quality of evidence (five studies) indicated that it differed not significantly between ES+MCE and non-ES controls (SMD=-0.20, 95% CI,-0.43 to 0.04, P=0. 0.10). Our results found out that the combination of electrical stimulation and motor control exercise had a beneficial effect for pain relief but no significant difference in disability outcome.

Conclusion: Our study supported the combination of electrical stimulation and motor control exercise to alleviate the chronic nonspecific low back pain. No significant difference for the disability outcome was observed in our study.

Keywords: Chronic nonspecific low back pain; Electrical stimulation; Motor control exercise; Randomized controlled trail; Meta-analysis

Abbreviations: LBP: Low Back Pain; CNSLBP: Chronic Nonspecific Low Back Pain; MCE: Motor Control Exercise; ES: Electrical Stimulation; NMES: Neuromuscular Electrical Stimulation; CENTRAL: Cochrane Central Register of Controlled Trials; CINAHL: The Cumulative Index to Nursing & Allied Health Literature; RCT: Randomized Controlled Trial; TENS: Transcutaneous Electrical Nerve Stimulation; PENS: Percutaneous Electrical Nerve Stimulation; GRADE: Grading of Recommendations, Assessment, Development, and Evaluation; SMD: Standardized Mean Difference; CI: Confidence Interval; VAS: Visual Analogue Scale; NPRS: Numerical Pain Rating Scale; Seven studies provided disability outcomes with MODQ: Modified Oswestry Disability Questionnaire; ODI: Oswestry Disability Index; ODQ: Oswestry Disability Questionnaire; RMDQ: Roland Morris Disability Questionnaire; NHP: Nottingham Health Profile; IO: Internal Oblique; EO: External Oblique; IG: Intervention Group; CG: Control Group; NA: Not Available; MODQ: Modified Oswestry Disability Questionnaire; tDCS: Transcranial Direct Current Stimulation; CSE: Core Stabilization Exercise; US: Ultrasound; IFC: Interferential Current; HMP: Hot Moist Pack; TMT: Trunk Muscle Training

Introduction

Low Back Pain (LBP) is a worldwide problem, which is defined as pain, muscle tension or stiffness localized below the costal margin and above the inferior gluteal folds, with or without sciatica (pain travelling down the leg from the lower back) [1]. According to the 2019 Global Burden of Disease Study, LBP is the leading health condition contributing to the need for rehabilitation services in 134 of the 204 countries analyzed, with 568 million people (505–640) and 64 million (45–85) lived with disability [2]. According to pain duration, low back pain is classified as acute (<6 weeks), subacute (6~12 weeks) or chronic (>12 weeks). Almost everyone has a brief, acute episode of LBP during their lifetime. 5~10% of the acute low back pain persist and develop into a chronic condition with fluctuating or persisting pain [3]. Many factors and risks contribute to pathogenesis of LBP, and patients with LBP are classified into four broad categories: those with a visceral disorder, a specific spinal disease, radicular syndromes or nonspecific low back pain [1]. The nonspecific low back pain probably develops from the interaction of biologic, psychological, and social factors, and accounts for approximately 80 to 90% of all cases of low back pain [4].

One of the pathophysiological theories is the spinal instability introduced by Panjabi [5]. In his theory, spinal stability seems to be a result of coordination among three major systems: active, passive, and neural. And lumbar segmental instability contributes to an increased range of motion, leading to the painful condition like Chronic Nonspecific Low Back Pain (CNSLBP). Muscles attributes to the spinal stability, which are divided into two types, the global and the local. The former provides general stability of the trunk, and the latter provides segmental stability [6]. Evidence advice that lumbar multifidus and transversus abdominis, two deep trunk muscles control the lumbar intervertebral movement [7]. Recent years, increasing attention has been paid to the preferential retraining of the local stabilizing muscles of the spine [8].

Considering the pathophysiological theory of CNSLBP is hard to define, the multidisciplinary treatment gets increasing attention. Exercise therapy is recommended as the main treatment and Motor Control Exercise (MCE) targets on activating of the deep trunk muscles to retrain the optimal control and coordination of the spine. MCE reduces the activity of superficial muscles, and pre-activates of the deep trunk muscles, with progression toward more complex static, dynamic, and functional task [9,10]. The motor control decreases pain and increases multifidus and transversus abdominis muscles thickness and lumbar mobility in patients with chronic LBP [8], but its benefit is not universal or complete. One of the theories is that the deep trunk muscles lack of immediate activation. To date, in patients with LBP, exercises targeting the lumbar multifidus, have failed to induce immediate changes in multifidus [11]. Electrical Stimulation (ES) is suggested as an adjunct to patients suffering the pain. It’s common that studies chose ES to enhance the effect of exercises [12,13]. ES entails several types. One modality widely studied is transcutaneous electrical nerve stimulation, which can alleviate the short-term pain. And Neuromuscular Electrical Stimulation (NMES) is effective in improving range of motion, reducing muscle spasm, and reducing pain in patients with LBP [14]. ES, NMES, in particular, provides feedback to the patient enabling reproducible muscle recruitment and activation. It also helps to retrain the transverse abdominis and multifidus while performing exercises [15], and is used to reduce immediate pain and provides another treatment for kinesophobia [16]. The trials that combined ES and MCE are increasing [16-18]. In order to see whether it could help to improve the condition of CNSLBP, we conducted this systematic review and meta-analysis.

Methods

Search Strategy

This review conformed to PRISMA guidelines [19] (Supplementary Table 1). The protocol for this systematic review was prospectively registered on PROSPERO (CRD42022324850). A systematic search was conducted in PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL) and the Cumulative Index to Nursing & Allied Health Literature (CINAHL) from the earliest record to 30 April 2022. We also searched additional records identified through other sources such as citation tracking and article reviewing. Search strategies followed the recommendations of the Cochrane Back and Neck Group [20]. We chose the key words mainly according to the Medical Subject Headings and entry items of it. To avoid missing the key words, we expanded it with relevant works. Specific subject subheadings and word truncations were used according to each database, with no language limitation. Detailed search terms were described in the Supplementary (Supplementary 2). Duplicate citations were eliminated after the preliminary search results were obtained. To identify the final studies that would be included in the meta-analysis, two independent reviewers (XYG, WWS) examined the title and abstract of each article for eligibility. Full articles were obtained and reviewed by two independent reviewers (XYG, WWS) on the basis of a standardized inclusion and exclusion criteria form. In the case of disagreement regarding whether a study meet all of the inclusion criteria and none of the exclusion criteria, a third reviewer (HHL) joined and identified until a common consensus was reached.