Low back pain (LBP) is a common disabling health problem that can cause decreased spine proprioception. Stochastic resonance (SR) can influence detection performance, besides improving patients with significant sensory deficits, but have not been thoroughly tested for LBP. This study aimed to examine the application of SR therapy (SRT) and strength training for LBP treatment. The subject was a resistance-trained male in his early thirties. His back pain was unbearable after a strength training session. Standard pain relief alleviated the pain but the LBP developed at a similar intensity after 4 weeks. SRT (4–5 sets ×90 sec, 30-sec rest interval, supine position) was prescribed along with other exercises for 3 weeks (phase 1), and followed by tailor-made strength training for 16 weeks (phase 2). The Oswestry Disability Index was 66.7% (interpreted as “crippled”) prior to first SRT, and reduced to minimal levels of 15.6% and 6.7% after four and seven SRT sessions, respectively. Similarly, pain intensity was ranging from 5 to 9 (distracting-severe) of the Numeric Rating Scale (NRS-11) prior to the first session but this was reduced considerably after four sessions (NRS-11: 0–1). During phase 2, the patient performed without complaining of LBP, two repetitions of bench press exercise at a load intensity of 1.2 his body weight and attained 4 min of plank stabilisation. This LBP management strategy has a clinically meaningful effect on pain intensity, disability, and functional mobility, by receding the recurrent distracting to severe LBP.
Low back pain (LBP) can cause a more global disability than any other condition. For example, LBP led to a considerable amount of ‘time missed,’ activity limitation, work absence, and disability throughout the world (
The majority of diagnoses of acute back pain are non-specific, or without a clear specific cause, but the central symptoms of LBP are pain and disability (
Although the cause of LBP is multifactorial, degeneration of the intervertebral discs has been linked to the triggering of LBP (
Recently, stochastic resonance therapy (SRT) has been used during rehabilitation programmes for normal and athletic populations. Stochastic resonance has potential to improve proprioceptive function (
The male subject in this study was in his early thirties (basic information withheld), resistance-trained, and presented no history of serious LBP in the last 5 years, except an intermittent and nonspecific mild low-back discomfort, which did not require medical attention nor caused any psychological distress. He had been able to engage with general strength training 3 times a week for a duration of 45–90 min during each session and participated in various physical activities without any symptoms of LBP. Additionally, he has also recorded three repetitions of 110 kg during the power clean (~1.4 times his bodyweight) a few weeks prior to his first complaint of LBP, attesting to his high fitness level. Relevant past medical history included acute LBP from sporting activities when he was 16, which caused significant pain and physical limitation for almost a week. This episode recurred a year later.
The patient approached the rehabilitation centre and requested an appropriate rehabilitation programme to be arranged for him. He also requested that the interventions and results be published to help others who suffer the same predicament, and to enable further exploration of the LBP intervention used in the present study. Meanwhile, the treatment was conducted with the consent of the patient, following the principles outlined by the World Medical Assembly Declaration of Helsinki, and was carried out by a qualified sport therapist with over 20 years of experience. The patient’s goals were to significantly reduce LBP, perform activities of daily living without restriction in movements, perform various strength exercises without an increase in pain, and reinitiate maximal strength exercise without pain.
The outcome measures that were used included the Oswestry Disability Index (ODI) and an 11-point Numeric Rating Scale (NRS-11) for self-reporting of pain. The ODI has 10 items scored from 0 to 5, and the overall score is expressed as a percentage, with higher scores indicating greater disability. A 50% pain reduction of the ODI has usually been considered successful. The NRS-11 is composed of an 11-point scale that is to be rated from 0 (no pain) to 10 (worst pain imaginable). A 2-point change on the rating scale was considered clinically meaningful. These subjective measures were completed in the morning before any physical activities took place. They were rated after simple flexion and extension movements (about ~30-sec duration) of the trunk. In addition, strength and stabilisation tests were conducted using the bench press and plank exercises, respectively. During evaluation, the patient’s history was taken and physical examination was carried out to determine functional restrictions, symptoms, risk factors, and neurological conditions.
The increased amount of work in his daily occupational roles in both sedentary office work (6–7 hr a day) and physical field work (3–4 hr a day) might have led to increased physical workloads. Having above average physical fitness, he was able to continue his active and intense lifestyle, which unfortunately could have led to increased tension in his body and lower back. The LBP flared up and was intolerable after he tried to rack a loaded barbell after performing a squat exercise (3 sets of 4–6 repetitions, ~1.8 times of bodyweight). He tried to find the best position to relieve the back pain, and ended up lying down for almost an hour while applying ice therapy. His initial thought was that he had a muscle strain. Ice therapy was applied 3 times for a duration of 10–15 min each, with each application separated by 3 hr during the first day, and three other applications were carried out the next day. He then arranged a clinical examination. The simple analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) provided by a physician did not seem very effective. This compelled him to seek further treatment after which he was given similar medications in addition to an injection to ease the pain. This procedure alleviated the discomfort about 10 days after the pain trigger from the strength training session. However, the episodes of acute pain did not completely dissipate.
Four weeks later, the pain occurred sporadically, ranging from 5 (distracting) to 8 (severe) on the NRS-11 during different times of the day. The sensation could be felt when standing or sitting for more than 10 min, and during muscular activities that required lifting, or efforts that required higher intensity rated from 4 (moderate) to 5 (challenging) on the rating of perceived exertion (RPE) scale of 10. This stress from the pain started to interfere with his daily work and life quality. However, a review of his clinical examination did not yield any suspicion of serious spinal abnormality. He was given another injection to relieve the pain, and subsequently advised by a physician to enter a rehabilitation programme.
A rehabilitation programme was designed to meet the patient’s goals. After the initial assessment by a physician, he met a sport therapist in order to be supervised closely throughout the rehabilitation period (
The tailor-made strength training was adhered to after seven sessions of the rehabilitation sessions. This included performing various free-weight and machine exercises that followed the principle of progressive overload (
The patient was observed during seven sessions in phase 1 of the rehabilitation period (3 weeks). The ODI was 66.7% prior to the first rehabilitation session, which can be interpreted as “crippling.” The next tests of ODI were carried out after the fourth and seventh rehabilitation sessions and scores of 15.6% and 6.7% were achieved respectively. These ranges can be interpreted as “minimal.” Meanwhile, the pain intensity of the NRS-11 ranged from 5 (distracting) to 9 (severe) prior to the first rehabilitation programme. LBP reduced considerably after two rehabilitation sessions (NRS-11 score: 4), and perceived normal after 4 sessions (NRS-11: 0 to 1). The scores of NRS-11 throughout phase 1 is shown in
This case study describes the use of SRT and strength training for LBP management. The primary finding suggests that the rehabilitation programme has a clinically meaningful effect on pain intensity and disability reduction, while restoring functional mobility. It is important to highlight that there was a ~51% reduction in pain and disability as assessed via the ODI after the 4th rehabilitation session, and a further ~8% reduction after 7th session, accumulating approximately 60% improvement in functional mobility and lifestyle after 3 weeks of the rehabilitation programme. A similar trend of changes was observed for the numeric rating scale. The lowest recorded pain intensity before the first SRT was 6, and from day 11 (after 4 SRT), the pain intensity seemed to stabilise at a low level (i.e., 0–1), that is reduction of ~5 points, which was considered meaningful. Meanwhile, the tailor-made strength programme that was commenced subsequently seems capable of averting the recurrence of LBP, while helping the patient to accomplish his goals during the period of observation. He performed various physical activities including strength exercises that were done without functional limitations and pain, and also reinitiated a maximal strength exercise (bench press) successfully without pain. With regards to pain reduction, a considerable symptom improvement after only 1 week was not totally unexpected as the patient was on a course of NSAIDs and he had also spent more time resting. Furthermore, the low frequency vibration during SRT may have provided muscle relaxation effects. Collectively, these factors could have facilitated the reduction of LBP.
A potentially favourable outcome of using the SRT was discussed extensively in the literature. Briefly, as the vibration is stochastic, it provides a randomised noise, in which the direction and the force-time behaviour of the vibrations are not foreseeable (unpredictable) and the body will be constantly challenged to adapt muscle reactions (
As LBP development is related to the degeneration of intervertebral discs (
Strength training has been recommended by the American College of Sports Medicine (ACSM) for various health and performance benefits (
The programme with free-weight exercises for LBP intervention may be employed based on the types of LBP and the timing of treatment application for better outcomes. Yet, it was difficult to determine which rehabilitation programme is better among the various modalities that examined the effects of exercise on LBP because different methodologies and tests were used. In the present study, phase 1 included exercises to improve the deep core muscles (stabilisation) to better prepare the body for the exercises performed during phase 2 that required greater intensity of muscles contraction. This approach might have addressed the limitations in the previous exercise rehabilitation studies, which did not sufficiently stress the large muscle groups to enhance the overall health of the musculoskeletal system (
Nonetheless, this case study is not without limitations. Ultrasound imaging or MRI might have been more accurate for assessing the severity of LBP. However, these objective measurements require additional devices that are often not readily available. Even though the results from a single subject may not be effectively generalised, it was also important to identify the specific exercises which are suitable and effective for an individual (as in this case study), as opposed to exercise prescriptions for a generic group since the major goal of the rehabilitation programme was returning the patient to an active lifestyle.
The primary outcomes of this case study demonstrated that a 3-week rehabilitation programme incorporating SRT and specific exercises was effective to reduce pain intensity and disability in a strength-trained patient with LBP. The tailor-made strength training enabled the patient to remain active and be able to perform various activities without movement restrictions, while potentially preventing the recurrence of LBP. Collectively, the intervention used in the present study has clinically meaningful effects on pain intensity, disability, and functional mobility. However, further studies are needed to better understand the current findings and its mechanisms.
No potential conflict of interest relevant to this article was reported.
Exercises performed during the rehabilitation program (presentation of this figure was approved by the patient). Leg sway (A), pronated elbow extension (B), swiss ball oscillation (C), and isometric curl-up (D).
Numeric rating scale (NRS) for pain intensity and stochastic resonance therapy (SRT) intervention throughout the 3-week rehabilitation programme.
Relaxation-stabilisation exercises and stochastic resonance therapy
Exercise | Variables | Benefits | Descriptions |
---|---|---|---|
Leg sway | 1–2 sets×2 min |
To promote a rapid symptom relief of lower back. | Sway the weighted leg gently and freely, forward and backward. |
Pronated elbow extension | 5–8 sets×8 reps |
To strengthen upper back and core. | Extend and flex the elbows (hold a stick in wide grip) in a controlled manner using a 303 tempo. |
Swiss ball oscillation | 1–2 sets×2 min |
To promote relaxation to lower back | Flat back against the floor or mat, both heels placed on Swiss ball. |
Isometric curl-up | 4 sets×5 reps (5 sec hold each) |
Abdominal strength | Flat back against the floor or mat. |
Stochastic resonance therapy | 4–5 sets×90 sec, rest 30 sec (trim 2–3) | Relaxation of back and increased proprioception | Flat back on the SRT machine, knee bent at 90°, and supported by a chair. |
General overview of tailor-made strength training programme
Variable | Week 1–4 | Week 5–8 | Week 9–12 | Week 13–16 |
---|---|---|---|---|
Basic exercises | ||||
Push up | 2–3×20–30 | - | - | - |
Squat | 2–3×20–30 | - | - | - |
Standing lunge | 2–3×20–30 | - | - | - |
| ||||
Strength exercises | - | |||
Bench press | 0.3–0.6 BW | 0.5–0.7 BW | 0.5–0.9 BW | 0.5–1.1 BW |
Overhead/push press | - | 20 kg | 20–40 kg | 30–50 kg |
DB Bent-over row | - | 10–15 kg | 15–20 kg | 15–25 kg |
DB Hammer curl | - | 10–15 kg | 15–20 kg | 15–25 kg |
Leg press | - | 40–80 kg plates | 80–120 kg plates | 80–160 kg plates |
Hexagon deadlift | - | 0.5–0.7 BW | 0.5–0.9 BW | 0.5–1.1 BW |
Seated calf-raise | 0.3–0.6 BW | 0.5–0.7 BW | 0.5–0.9 BW | 0.5–1.1 BW |
| ||||
Stabilisation exercises | ||||
Back extension without arms | BW | BW | BW | BW |
45° back extension | BW | BW | BW | BW |
Glute bridge | BW | BW | BW | BW |
Bird dog | BW | BW | BW | BW |
Cat and camel | BW | BW | BW | BW |
Plank (front/sides) | BW (30 sec) | BW (30–45 sec) | BW (30–60 sec) | BW (30–90 sec) |
Flutter kick | BW | BW | BW | BW |
Bridging | BW | BW | BW | BW |
Curl up | BW | BW | BW | BW |
Scissors | BW | BW | BW | BW |
BW, bodyweight; DB, dumbbell.
Number of exercise=2 BW exercises, 2–4 strength exercises, and 2–4 stabilisation exercises during each session. Exercise frequency=2–3 times weekly on nonconsecutive days. Number of set=2–3 sets during each session. Number of repetitions=3–15 repetitions for strength exercises (endurance: 1×12–15, hypertrophy: 1×8–12, strength: 1×3–6) and 10–20 repetitions for stabilisation exercises. Tempo=moderate. General training objectives=to execute exercises with a sound biomechanical technique and to develop general strength.