Non-Specific Low Back Pain is a major health problem worldwide. Interventions based on exercises have been the most commonly used treatments for students with this condition. Over the past few years, the Pilates method has been one of the most popular exercise programmes used in clinical practice.
To compare the effectiveness of Mat and Swiss Ball Based Pilates Exercise on functional disability in terms of Modified Oswestry Disability Index (MODI) and Endurance in terms of Ito Test in Students with Chronic Non Specific Low Back Pain (CNSLBP).
40 participants between the age of 18 to 25 years with the clinical diagnosis of CNSLBP were selected. Participants were randomly divided into Group (A), which received Mat Pilates exercise and Group (B) received Swiss Ball Pilates exercise for 4 weeks of duration under the guidance of therapist. Pre and post intervention assessments were done.
There was a significant difference seen on comparison between the individuals pre and post interventional statistics of both Groups, nevertheless, when comparison was made between the Post results, there was a significant difference in Group A as compared to Group B.
The current study concluded that Mat based Pilates exercises showed more improvement in both the variables.
The Lumbo-Sacral area of the back is also known as lower back. It is made up by the muscles that are attached and surrounds the spine. The spine is made up of many bones called vertebrae and between each vertebra is a disc. The discs are a combination of a strong fibrous outer layer and a softer, gel-like centre called as nucleus pulposus, is present between the vertebrae. Inter vertebral disc act as shock absorber, allow the spine to be flexible. To give extra support and strength to the spine ligaments are attached to nearby vertebrae. [1] Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. [2] Low back pain is the second most common cause of disability in adults. [3]The low back pain can be categorized on the basis of the duration and etiology. On the basis of duration low back pain can be classified as acute, sub-acute and chronic. Acute low back pain is in between 0 and 6 weeks, Sub-acute low back pain is in between 6 and 12 weeks and chronic low back pain is more than 12 weeks. [4] On the basis of etiology the incidence or progression of low back pain includes the mechanical aspects of the system (i.e., compression, tension, shear, torsion, rate of loading) along with physiological, psychological, socioeconomic, and psychosocial factors. [5]Non specific low back pain; Non specific low back pain is the most common type of back pain; it can develop for no apparent reason. The severity of the pain can range from mild to severe. Sometimes a pain may develop immediately after you lift something heavy, or after an awkward twisting movement. [6]Chronic non specific low back pain can be treated by various methods like modalities, William’s flexion exercises, McKenzie exercises but it has been shown that Pilates exercise have more beneficial effect on chronic non specific low back pain. Pilates exercises mainly involve isometric contractions (i.e. contraction without joint movement) of the core muscles, which make up the muscular centre responsible for the stabilization of the body, both while it is moving or at rest [1].
The participants were selected as per the inclusion criteria and participants were explained about the intervention. 40 subjects were selected and allocated into 2 groups; 20 for mat and 20 for swissball [2]
Group A: Pilates exercises given on mat
Group B: Pilates exercises given on swissball
Modified Oswestry pain and disability index - The Oswestry Low Back Pain Disability Questionnaire can be used to assess patients with low back pain by determining its impact on the activities of daily living.
Ito-test-
For evaluating flexor endurance, subjects were asked to lie in a supine position and to raise the lower extremities with 90° flexion of the hip and knee joints.
For evaluating extensor endurance, subjects were asked to lie in a prone position while holding the sternum off the floor. A small pillow was placed under the lower abdomen to decrease the lumbar lordosis.
During both procedures, subjects were asked to maintain their maximum flexion of cervical spine, with pelvic stabilization through gluteal muscle contraction. Participants were instructed to perform stretching of obliques, transverse abdominis rectus abdominis and spot jogging for 10 minutes before and after the pilates exercise. Pre and post pain can be evaluated by using Modified Oswestry low back pain and disability questionnaire and core strength can be evaluated by Ito-test. Both groups were asked to perform 4 types of core stability exercises for relieving chronic non specific low back pain while focusing on five key elements which are neutral spine, core centering, shoulder blade placement, rib cage placement, head and neck placement. Common Pilates based exercises on swiss ball and mat in this study are: Bridging, Curl up, The hundred prep, Front plank Exercise for mat Group [3].
Participant was positioned in crook lying with hands at the side of the body, palm facing downwards. Hips were slowly raised off the ground so that only forearms and heels are in contact with the ground with weight supported across the shoulder area. Avoid pressing the cervical spine into the floor. Lumbar and cervical spine was in neutral position throughout.
Curl-up on mat Participant was in crook lying with arms over the head then shoulders and upper back were lifted off the ground. The trunk was slowly curled and returned to the starting position. Avoid pulling on the head or neck. Neutral posture was maintained between each repetition [4].
The hundred prep: Participant was positioned in supine position, the movement was initiated from the core with elbow under the shoulder and upper arm parallel to the ground. The head was flexed then the leg was lifted to 90-90 and the arm was pumped till 5 counts. Participant was instructed to inhale during the initiation of movement and exhale during the head flexion and lifting the leg to 90-90 [5].
Front plank on mat: Participant was in front plank position with elbow under the shoulder and upper arm perpendicular to the ground. Shoulder and pelvis were raised slowly off the ground; supporting points were elbow and feet. Balancing the forearm under the shoulder, the spine was kept in neutral and the lower abdomen was drawn in [7].
Bridging on Swiss ball: Participant was positioned in supine position by placing the arms outwards. The feet were placed on the ball, toes pointing forward. The abdominal muscles were drawn in towards the spine. The abdominals and gluteus were contracted and hips were raised off the floor. Ensure that toe should be in neutral position. Avoid the outward rotation of the toes.
Curl-up on Swiss ball: Participant was in supine position with lower back supported on the ball. Hands were clasped behind the head and feet were shoulder width apart then the lower abdominal muscles were drawn in towards the spine. The spine was slowly flexed with the abdominal muscles drawn in and the cervical spine was kept in neutral with the chin tucked.
The hundred prep: Participant was in supine position with elbow under the shoulder and upper arm perpendicular to the ground and leg bent to 90-90 on swiss ball. The head was slowly flexed then the arm was pumped till 5 counts. Participant was instructed to inhale during the initiation of the movement and exhale during the head flexion.
Front plank on Swiss ball: Participant was in front plank position on the Swiss ball with elbow under the shoulder and upper arm perpendicular to the ground. Shoulder and pelvis were slowly raised off the ground; supporting points were elbow and feet. Balancing the forearm under the shoulder, the spine was kept in neutral and the lower abdomen was drawn in.
This protocol was given for 5 days for 4 weeks with 8-10 repetitions of all the exercises per session, baseline characters were Ito test and Modified Oswestry Disability Index was taken on first and last day of treatment and then results were tabulated.
| GROUPS | MEAN OF AGE IN YEARS | SD OF AGE IN YEARS |
| GROUP A | 20.2 | 2.215 |
| GROUP B | 20.55 | 2.089 |
The average age of Group A was 20.2 +_ 2.215 years and in Group B was 20.55+_2.089 years.
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There were12 (60%) male and 8 (40%) female in Group A receiving Mat Based Pilates. There were 14(70%) male and 6(30%) female in Group B receiving SwissBall Based Pilates. The duration of treatment in both the Groups was for 4 weeks.
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GRAPH 1.3
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GRAPH 1.4: Comparison of pre and post ITO test for extensor endurance in Group A and Group B using paired t test in which p value for mat is <0.0001and t value is 10.467 it is considered extremely significant and for swissball p value is <0.0001and t=7.611 it is considered extremely significant.
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| GROUPS | INTERVENTION | MEAN | SD | t value | p value | RESULTS |
| GROUP A | POST | 35.8 | 15.296 | 2.777 | 0.0285 | CONSIDERED SIGNIFICANT |
| GROUP B | POST | 25 | 14.690 |
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| GROUPS | INTERVENTION | MEAN | SD | t value | p value | RESULTS |
| GROUP A | POST | 2.85 | 1.785 | 3.444 | 0.0014 | CONSIDERED SIGNIFICANT |
| GROUP B | POST | 1.4 | 0.5982 |
Low back pain is a condition which can be treated by wide variety of physiotherapy interventions. Present study was undertaken to find out effectiveness of mat and swissball based Pilate’s exercise, by using ITO test for core strength and endurance and modified Oswestry pain and disability scale. The intervention included 4 Pilate’s exercises given to all the participants in Group A and Group B on mat and swiss ball respectively for 3 weeks. The four Pilates exercises which are used to relieve low back pain are: bridging, curl up, hundred prep exercises, front plank. Bridging, a body weight strength training exercise, helps muscles in the back and hips (erector spinae, gluteus maximus, hamstring) to work together to coordinate the lifting of the hips and also improves the strength of core muscles. Curl ups are an effective way to strengthen the muscles of your abdomen specifically the rectus abdominis, external and internal oblique. During hundred prep exercise, breathing and percussive pumping of arms not only increases oxygen exchange and blood circulation but also activates pelvic floor muscles and abdominal muscles. During front plank body weight borne on forearm, elbows, and toes strengthens erector spinae, rectus abdominis, transverse abdominis, trapezius, rhomboids, deltoid, pectorals, gluteus maximus, quadriceps, and gastrocnemius. The results of the present study are such that, intervention given on mat and swiss ball showed significant changes in the strength of muscles but when the effects of the intervention on mat and swiss ball were compared no significant changes were seen according to ITO test whereas according to MODI, pain and disability index were reduced more when participants were trained on swiss ball than on mat. As per our knowledge this is the first study which compares the effect of mat and swissball based pilatesexercisesin students with chronic non specific low back pain with 4 weeks of intervention.
Mat Pilates concentrates mainly on Mat Based Pilates Exercises, is a gentle form of exercise which makes it more suitable for the patients with back pain and those recovering from injury. Pilates can also help to prevent the recurrence of low back pain. Uses of Mat based Pilates Exercises; it eases back pain, Strengthen the core, Increases your flexibility, It makes a great cross training workout, Improves posture, It builds cardiovascular endurance mat has a stable surface which provides sufficient stability to the spine preventing injury that occurs from uneven stress patterns on back and discs. It also improves the mobility of the hip and shoulder joints, balancing the sides of the body, aiding in creating postural symmetry which may trickle into the individual’s daily awareness of how they hold their body during daily activities.
The Swiss Ball is widely used in the recreational training environment to be a training device for core stability exercise .The Swiss Ball is a conservative treatment option for back pain sufferers and is designed to help prevent further episodes of low back pain as part of a rehabilitation programme. Uses of Swiss Ball Based Pilates Exercises; Improve muscle tone and endurance, improve posture, improve balance, increase flexibility, experience greater self confidence and the body responds naturally and automatically to this instability to keep balanced on the exercise ball. Over time, the muscle used to keep in balance on the Swiss Ball become stronger. In essence, individuals build strength in important back muscles and abdominal muscles without knowing it. SwissBall has a dynamic surface in which the level of muscle activity increases and in order to stabilize the spine, muscles co- activation takes place, suggesting a higher demand on the motor control system . More muscle activity is seen when exercises are performed in mid range.7The biggest benefit to training using Swiss Ball Exercises is that they are very effective at targeting core muscles, those muscles that are essential for stability and good posture but are often overlooked when exercising in fixed position.
From the above analysis, it is clear that both core stabilisation exercise on Mat and SwissBall have an effect on improving the endurance by Ito Test and reducing the pain and disability among Chronic Non Specific Low Back Pain on MODI. There is significant difference on core stabilisation exercise on Mat compared to core stabilisation exercise on SwissBall between 2 Groups. Hence our Null Hypothesis is rejected and Alternate Hypothesis is accepted. This result suggests that the core stabilisation exercise with Mat is more effective than the core stabilisation exercise on SwissBall in improving endurance and reducing pain and disability among Chronic Non Specific Low Back Pain participants in a very short period of time.
Indeed I am very glad to present this project as a part of my Internship. I wish to express my sincere gratitude to all those who really helped with it. I am truly blessed by the constant support of my principal Dr. SubhashKhatri and his worldly advice and counseling at every step. I wish to express my deep gratitude to my professor and my project guide Dr. KeerthiRao who has helped me to choose this project topic and provide me with constant guidance and support throughout the project. I wish to thank all my professors and my senior colleagues for their cooperation, tolerance and guidance all throughout this project. I express my special thanks to all my friends for their support throughout and all other participants for their unconditional understanding and co-operation. They are an essential part of my project. My sincere thanks to all enthusiastic participants who volunteered and made it possible to withdraw a conclusion. I would like to bow to THE ALMIGHTY and MY PARENTS whose blessings, love and encouragement have always been a catalyst in all walks of my life.
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Ståhl M. Non-Specific Neck Pain In Preadolescent To Adolescent. Finland: Hjelt Institute University of Helsinki, Department of Public Health, 2014.
freburger J, Holmes G, Agans R, Jackman A, Darter J, Wallace A. The rising prevalance of chronic low back pain. Archieves of internal medicine. 169(3), 2009, 251- 258.
SK. Basics of Orthopedic Physiotherapy New Delhi: Jaypee Brothers Medical Publishers Ltd, 2013.
Olson W. 2006. [cited 2016 November. Available from: http://etd.lsu.edu/docs/available/etd-03202006- 080052/unrestricted /Olson_dis.
Non-specific Lower Back Pain in Adults, 2016. [Online]. [Cited. Available from: http://patient.info/health/nonspecific-lower-back-painin-adults.
Balakrishnan R, Yazid E, Mahat MF. Effectiveness of the core stabilisation exercise on floor and Swiss ball on individual with non-Specific low back pain. International Journal of Physical Education, Sports and Health.3 (1), 2016, 347-56.