Introduction

In our highly industrialized world ,low back pains (LBP) has become a major health issue because of
its high prevalence in the genera l population and adverse effects on health. Low back pain is a
general term characterized by acute (<6 weeks) subacute 6 -12weeks).or chronic (<12 weeks) pain,
all of which are durations dependent and locations spesific. in the health care profession LBP is
knows by various names and treatment differaccordingly. General practitioners may use lumbago
;physiotherapist may call it hyperextension ,a manual therapist may call it facet joint disorder,and
orthopedic surgeons may call it a degenerative disc problem . however, at present no reliable and
valid classification system exists for diagnosis and prognosis of LBP

Low back pain is not necessarily a consequence of degenerative processes many patients
with recurring LBP have no evidence of degenerative changes have no back pain. Numerous
hypothese concern the cause of nonspesific LBP ,including reduced trunk extensor endurance (18)
psychological distress(5)hamtring flexibility(12) poor muscle control of the trunk (11) poor
posture(23) and low body mass( 23)

LPB is a multifactorial disorder with many possibel cause treatment for LPB varies cnsiderably. It
includes mediction ,physical theraphy modalities, and exercise theraphy(31),and each have several
intervention .practice guidelines recommend various thype of exercises and manipulative theraphy
for chronic LBP, but there have been few head to head comparinsons of these interventions (20). In
recent years, multididsciplinarypain program were seen to succesfully treat patients by basing
treatment on a combination of physical exercise and psychlogical intervention(28) however, despite
their effectivenees, it still remains to be clarified exactly which features of these programs were
responsibel forpatient improvement (28) intervention such as the appcilation os heat,short wave
diathhermy(SWD) and massage alone have inssufficient evidence to supports their effectiveness at
present, but they were found to be effective and more cost effective than no intervention.

Athletes , especially hockey players,are more prone to LBP as a result of theirs regularforwad
bending play ,which leads to derangement syndromes. This derangement not only destruct their
skills and ability to play, but also produces strees and,in the log run ,disability. Therapeutic exercise
,as part of rehabilitations for patiens with LBP, is on of the treatment modalities most commonly
used by physiotherapist(21) in the management of such cases , the dynamic muscular stabilization
techniques (DMST) were found to be effective(17) through DMST adequate dynamic control of
lumbar spine forces is achieved thus reducing the repetive injury to the structures of the spinal
segments and related structures. specific stabilizing exercise with co-contraction of deep abdominal
(transvesus abdominis) and lumbal multifindus muscles enhance the spinal segmental support and
control (30). In recent clinical trials, these exercise have proved effective in the management of LBP
in the short and long term(10)

No randomized comparisons have been done of the effects of general exercise and spinal
manipulative therapy specifically for the management of chronic LBP, so it was not clear which of
the threatment is most effective(20). There is still no evidence as to which training is best for
differens subgroups (19,27) in clinical reality, modalities and training are often is used combination
to relieve pain and improve function. Patients often get better, but the pain recurs frequently and
many patients urdergo treatment again and again.
Keeping these facts in mind to and to the best of our knowledge , for the first time the combination
of 2 electrotherapy (ultrasound and SWD) and 1 exercise therapy (lumbar strengthening exercise
(LSE) was named “conventional” and compared with “DMST” an active approach of stabilizing
training. We hypothesis that DMST may be more effective than conventional in the management of
subacute or chronic low back pain. To test this hypothesis ,this study was designed and the effect of
2 independent variables( days and treatments) were assessed on 4 independent variables : walking,
stand ups, climbing, and pain.

Methods

Experimental subject were randomaly assigent equally into 2 groups by a lottery methods. For
this,30 folded papers of the same shape and size were marked either convetional or DMST kept in
abox and mixed thoroughly before and after with drawing a paper from the box by the playeron a
first come ,first serve basis. The marking on the peper drawn by the player allocates his mode of
treatment. All tests were performed for dependent variables (walking,stand ups, climbing, and pain)
by the same tester and same physiotherapist supervising the test procedure at baseline and on days
21 and 35. Test and retest were conducted in the same place at the same environment and at the
same time of the day. The interval between test and retest was 21 and 35 days from baseline.
Subject were told not to eat for 2 hours before each test. Before experimentation, all subject were
taught about the measurement variables and their outcomes. The player were also informed about
the experimental risks, if any.

Subject

a total of 30 male hocked player from sports authority of india (SAI), lucknow, aged 18 to 28 years
who were diagnosed clinically by a physician with no neurological involvement but having
symptomatic (overuse,overload,or overstretching) nonspecific subacute or chronic low back pain
(CLBP) were included for this study. After randomization , players physical and other characteristics
were taken (table 1). The baseline mean age ,weight, height,and BMI ( body mass index) of the 2
groups and other characteristics such as gender, type of pain , duration of sports training, and
nutrition intake were found to be the same . the present study has the approval of the institutional
review board, and informed consent was obtained from the hocked coach ,SAI, lucknow, and from
all the participants.

Procedure

After group allocations, respective subjects were treated either with conventional or DMST. Both
the treatments were given as individual treatments by the same physiotherapist with the same
intensity and capacity on alternate day for 35 days. The duration of each individual theatment
session was about 40 minutes per day. The subjects were not allowed to receive any other
theatment , including pain killers. A brief description of both the theatments used follows:

Conventional theatment . ultrasound, SWD, and lumber strengthening exercise

Ultrasound (US). For the purpose of the study as a theatment for a chronic condition , a frequency of
1 MHz was used rather than 3 MHz, which penetrates least and is absorbed superficially (7).
Continous pattern ultrasound is recommended for used in chronic conditions at intensity 1,2 W/cm2
for a period of 8 minutes for 18 sittings in 18 alternate days. Ultrasound equiepment was used from
medhichem electronics,which has international standart certifications.

Short-wava diathermy. SWD is a deep heating modality used in relieving pain. It is also used to
enhance flexibility and blood flow and reduce inflammation. Short-wave forms are used for selected
patients without neurological lesion. Continous mode of SWD is used for 15 minutes with 18 sittings
in 18 alternate days. The SWD was used from Medichem electronic s, which has international
standard certification.

Lumbar strengthening exercises. The use of LSE are well documented, including spinal extension
exercises and trunk extensor muscles exercises. LSEs were done for 10 repetitions each exercise per
sitting on alternate days.

Dynamic muscular stabilization treatment. In DMST, muscle with direct attachment to the lumbar
spinal segment stabilize the joints “neutral zone” and prevent excessive deflection. Exercise is given
in 4 stages (figure 1) in the following order

First week : isolation and facilitation of target muscles. Verbal instruction such as drawing in and
hollowing the lower abdomen, drawing the naval up and in toward the spine, or feeling the muscle
tighten at the waist. From the beginning the patient learns to breathe normally while activating or
holding the muscular contraction, the patient is in supine hook lying position and instructed to
perform abdominal hollowing (in which the patient is instructed to make the lower abdomen cave
in) or abdominal bracing (in which the patient is instructed to contract the abdominals by actively
flaring out laterally in the region of the waist just above the iliac crest)

Second week : training of trunk stabilization under static conditions of increased load. The patient’s
position and concentration pattern are the same as the first week; the individual is then asked to
hold the position while load is added via the weight of the lower limbs being moved passively into a
loaded position

Third week : development of trunk stabilixation during slow controlled movement of the lumbar
spine. Once stability is trained through static procedure, the movement of the trunk will optimize
the activation of the muscle. The first step is to produce and explore lumbopelvic movement and
learn abdominal hollowing or bracing in a variety of positions: sitting, quadruped, standing supine,
kneeling, and inclination by degree to control loading

Fourth and fifth weeks: lumbar stabilization during high-speed and skilled movement. High-speed
phasic exercises are recommended to the patient along with abdominal hollowing or bracing in a
variety of positions

Response (dependent) variabels

The effects of treatments were assessed on 5 minutes of walking distance (m/5 minute), per-minute
number of stand ups (number/min) and stair climbing (number/min), and level of pain (cm) on day 0
(before the treatment), day 21 (during the treatment),and day 35(end of the treatment). The
functional ability (walking, stand ups, and climbing) were measured according to the Waddle
functional evaluation test (33), whereas level of pain was measured by the visual analogue scale
(VAS: 0-10cm) (13), the measuring details of variables in brief are summarized as follows:

5 minutes of walking. The distance of a walk up and down between marks 10 m apart in 5 minutes.
The corridor was quiet and empty with a nonslip surface of hard carpet. The patient could not use
any walking aid but could use the walls for support or sit down for a rest. Regular information about
the time was given to the patient between walking.

One minute stand ups: the number of times the patient can stand up from a chair in 1 minute is his
score. The chair was firm and upright with a back rest but no arm rest. The seat height of the chair
was 45 cm. during stand ups, there was no support within reach so the patient could not use any
support.

One minute climbing. Climbing up and down standart stairs with 1 handrail and an opposite wall
within easy reach were used. Stairs climbing counts of a patient were taken as total steps ups and
downs completed in 1 minute (eg.,a patient can go up 10 steps and down 18 steps, so the total
counts are 28)

Visual analogue scale. The VAS is a 10-cm calibrated line with 0 representing no pain and 10
representing the worst pain. The subjects were asked to make a mark or point on the scale that best
represents his intensity of pain experienced. The distance between 0 and the mark or point was then
recorded.

Statistical analyses

The effect of 2 independent factors (days and treatments) on each of 4 dependent variables
(walking, stand ups, climbing, and pain) was assessed by 2-way analysis of variance (ANOVA) with
repeated measures (within treatments) followed by Newman Keuls post hoc test. Before performing
the ANOVA, the homogeneity of variance testing for each interaction (days >< treatments) was done
by Hartley, Cochran C, and Bartlett Chi-square methods. The relative association of each variable
with time (days) and among variables for both the treatments was assessed separately by Pearson
correlation coefficient (r), whereas functional dependence by regression analysis, considering time
as independent variable and outcome of the variable over the period as dependent variable and
their coefficients (α and β) were compared by t-test. The test-retest reliability of both the
independent factors of each dependent variable was assessed by intraclass correlation coefficient
(r1). A 2-tailed probability value less than 0.05 (ρ ≤ 0.05) was considered to be statistically
significant. Microsoft Excel (MS Office 97-2003), GraphPad Prism (version 5), and STATISTICA
(version 7) were used for the analysis.

For easy interpretation of the data, a percent change (from baseline to end of treatment) was
calculated as follows:
Mean1−Mean2
Change (%) = Mean3
X 100

Results
The functional ability (walking, stand ups, climbing) and level of pain of 2 treatment groups were
summarized in table 2, and responses of each individual over treatments were shown graphically in
Figure 2. Table 1 shows that the average functional ability in both the treatments increases in
functional ability and decrease in pain seems to be higher in DMST than in the conventional
treatment.

Table 3 showed tha the variance of interaction (days >< treatments) was homogeneous (ρ ≤ 0.05).
the analysis of Variance revealed that both days and treatments have significant (p<0.01) effects on
walking, stand ups, climbing, and pain (table 3). Their interactions (days X treatments) were also
significant (p<0.01), except climbing. The subjects’ matching was effective (p<0.01). in both the
treatments, the mean levels of all variables between days (within subjects) differed significantly
either at p<0.05 or p<0.01, except walking in conventional ( day 0 and day 21) (table 2).

Similarly, the mean levels of all variables differed significantly (p<0.01) between treatments
(between subjects) except on day 0. The levels of all variables on both day 21 and day 35 were
significantly high (p<0.01) in DMST than in conventional, except pain, which was similar (p>0.05)at
day 21.

Correlation

Table 4 shows that all functional ability of both the Treatment has significant (p<0.01) and positive
correlation with the time (days), whereas pain has significant (p<0.01) and negative correlation. The
correlations of variables with time and among variables were comparatively higher in DMST than in
conventional.

Regression

Comparing regression (Table 5) coefficients (alfa and beta) the intercept (alfa) of all variables in 2
groups did not differ significantly (p>0.05), whereas slopes (beta) differed significantly (p<0.01)
higher in DMST than in the conventional.

Test-Retest Rellability

The test-retest reliability of both the independent factors (days and treatment) for each dependent
variable was assessed separately by intraclass correlation coefficient reliabilities (ICCRs). The
dependent variable-walking, stand up, climbing, and pain-shows high reliability of 0.997, 0.995,
0.977 and 0.995, respectively, for days and 0.998, 0.995, 0.915, and 0.981, respectively, for
treatments.

Responders / Nonresponders

The response of the treatments on subject’s functional ability (walking, stand ups, and climbing) and
pain was assessed separately by substracting successive-day response from previous-day response.
The 0 or negative score was considered as nonresponse and possitive score was considered as a
favorable rosponse. Table 6 showed that in both the treatments the proportions of responders are
higher then the nonresponders and higher in DMST (99.2%) than in conventional (95.0%) and the
responders are higher than the nonresponders and higher in DMST (99.2%) than in conventional
(95.0%), and the responders were higher at day 21 than at day 35. In both the tratments, subjects’
response over pain was the most (100.0%) and their response of climbing was the least (96.7%). No
major adverse effects were recorded in any of the patients in either group.

DISCUSSION

In the present study both therapies (conventional and DMST) are found to be effective in the early
recovery of patients with subacute or chronic low back pain, especially in pain control. The
hypothesis that the conventional was found to be true. The DMST showed net improvement (%
mean change from baseline to end of the treatment) of 7.0, 34.8, 34.6, and 79.2%, respectively, in
walking, stand ups, climbing, and pain, whereas improvement in the conventional treatment group
was 1.5, 17.7, 24.5, and 38.1%, respectively, which was 4.7, 2.0, 1.4, and 2.1 times higher,
respectively, in DMST than the conventional. The correlation of walking, stand ups, climbing, and
pain with time (days) suggests that all variables in DMST improved with time more significant than
the conventional; regression analysis (ratio of beta coefficients) showed that it was 4.9, 2.5, 1.6, and
2.3 times higher, respectively, in DMST than the conventional. In both the treatments, the
proportions of reponders are higher than the nonresponders and higher in DMST (99.2%) than the
conventional (95.0%). In the present study, variance of interactions (days X treatments) are
homogeneous, subject matching was perfect, and test-retest reliability of both independent factors
(days and treatments) of all dependent variables are significant. The mechanism by which these
treatments improved LBP is not clear. We think that in conventional treatment, limited muscle
groups were imvolved and not aimed at improving strength. In DMST the more improvement may be
a result of restored muscle strength in combination with balance, posture, position, and
coordination inthe presence of pain and functional disability.

Previous comparative study among stabilizing training with manual treatment shows that the
individual of stabilizing group more improved than the manual treatment group (6). A systemic
review of the efficacy of McKenzie therapy also results in a greater decrease in pain and disability in
the short term than other standard therapies (3). In a comparative study, the manipulation
treatment with stabilizing exercise was found more effective in reducing pain intensity and disability
than the physician consultation alone (26). In another study, pulsed SWD was compared with
continous SWD in LBD and pulse SWD was found to be more effective than continuous SWD (25). A
study was done to compare. Congnitive interventions and exercise in patients with chronic LBP and
the effect of both the treatments were found to be similar (1) in a study that compares manipulative
theraphy with massage and SWD,the effect of manipulation and stabilization exercises in patients
with LBP suggests that patients with lumbarhypomobility experienced greated benefit from
manipulation and those having hypermobility were more benefited by stabilization exercises(8)one
study showed that patients with chronic low back pain demonstrateda reductiond in performance of
trunk extensor and flexor muscles when compared with a control group while using convetional
trunk streinghtening exercise . this study also suggest back extensor muscle deficiency should be
considered in planning rehabilitation program for patients with chronic low back pain and
recommends that if passive modalities fail to restore function in 1 month. Then active care or
stabilizer muscle activation through stabilization exercises is needed.

All guidelines consistently report acute LBP typically has an excellent prognosis because
most cases (up to 90%) recover with in 6 weeks (29,32) .musculoskeletal physiotheraohy has seen an
increase in the prescription of exercise to rehabilitate spinal stability in patients with chronic low
back disorder (30) however, the prognosis for acute low back pain during play activity has been
investigated and has been conffidently resported as exellent in all current clinical practice guidelines
for the management of acutelow back pain(14).

Correct and timely rehabilitation is a vital component of the theatment of sports injuries.
The goals of rehabilitation include restoring function , restoring pain-free full range of mation, and
achieving full mucle strength and sports endurance. Generally , sports rehabilitation entails a
phased approach including progressive exercise and therapeutic modalities to achieve full recovery,
this paper discusses the rehabilitation of LBP with the application of DMST and a special focus on
the transverses abdominus and multifidi muscles, which is a necessary part of physical therapy for
LBT. Literature review suggests that there is a need for this type of comparative study in cases of
sport injury rehabilitation . exercise programs may play in important part in muscle strengthening
and prevention of future or recurrent injuruies : there also may be important psychologic benefits.
Lumbar Stabilization exercises are aimed at sensorimotor reprogramming of spine stabilizer muscles
intended to improve their motor control skill and delay of response and consequently to
compensate for weakness of the passive stabilization system. Our results cannot be generalized to
other populations because all subjects participating in this study were players. Therefore, the
benefits of lumbar stabilization used in this study should be confirmed in other populations, which is
our next aim.

Practical applications

Overuse injuries are common in sports, especially hockey, affecting predominantly the ankles and
lower back. Physiotherapists, especially sports physiotherapists, were less concerned with a
systematic approach (prospective) and the majority were taken from cases in which the
rehabilitation intervention had been completed (retrospective) or used their experiences. This study
concludes that for the management of low back pain, DMST is more suitable than conventional
treatment. DMST than in conventional treatment. The findings can be helpful to care providers,
therapists, and people with chronic back pain.

ACKNOWLEDGMENTS

One of the senior authors is a PhD scholar and was a physiotherapist attached with SAI, Lucknow.
The authors want to acknowledge the direcotr, SAI, Lucknow, and coaches, especially hockey coach
Mr. Raja, for their necessary help and Mr.Madhusudan Tiwari, assistant physiotherapist, for helping
in taking the measurements. In addition, we acknowledge ICMR New Delhi for providing a Senior
Research fellowship .