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INTRODUCTION

In both developed and developing nations, low back pain is the most common reason for years of disability and ranks sixth in terms of the burden of all diseases¹. It is a common complaint that has been linked to worse quality of life (QOL) and activities of daily living (ADLs)². Compared to the overall population and other ethnic populations, the Indian community has higher point, yearly, and lifetime  prevalence  rates  of  LBP,  which impacts a sizable fraction of the population, particularly among women, rural residents,  and  elementary workers³.

Depending on pain duration low back pain can be classified as acute (lasting less than  6  weeks),  subacute (lasting between 6 and 12 weeks), or chronic (lasting beyond three months)⁴.Pain between the 12th rib and the inferior gluteal folds, with or without leg pain, is defined as low back pain. The majority of instances are non-specific, but in 5–10% of cases, a particular cause is identified. Some degenerative problems, inflammatory illnesses, infective and neoplastic causes, metabolic  bone  disease,  referred  pain,  psychogenic pain, trauma, and congenital disorders are specific causes of back pain. Back pain with no known underlying pathology is referred to as non-specific Low back pain⁵.

Exercise has the most evidence of success for  treating  chronic  low  back  pain,  with  greater  advantages  in terms of pain and function than any other treatment. A wide range of exercise programs have been developed; nevertheless, "lumbar stabilization exercises" have grown in popularity among clinicians who treat spine diseases⁶. In patients with non-specific low back pain, lumbar stabilization exercise is more beneficial than regular physical therapy exercises in terms of pain reduction⁷. In  current  practice,  stabilizing  exercises  are used to increase the endurance, strength, and flexibility  of  the  core  muscles⁸.The  transverse  abdominis muscle, which attaches to the vertebra via the thoracolumbar fascia, aids in spine stiffening by promoting intra-abdominal pressure⁹.Exercises for lumbar stabilization are designed to enhance  the  neuromuscular control, strength, and endurance of the muscles that are essential for preserving the dynamic stability of the spine and trunk. The efficacy of lumbar stabilization exercises on people with low back pain, pelvic pain, and LBP with leg pain has been studied¹⁰.

Numerous treatment options exist, including prescription drugs, physical therapy, various forms of exercise, and guidelines for back-friendly working practices¹¹.Back school (BS) program is an educational curriculum designed to prevent pain in the back and help people with degenerative spine conditions get better. Back school programs use theoretical and practical instruction in subjects including exercises, spine anatomy, biomechanics, best posture, and ergonomics to help patients become active participants in their recovery and in the maintenance of their quality of life¹².Although back schools have been practiced since 1969, their benefit in preventing or treating back pain has not yet been conclusively shown. A Cochrane review reasoned that back school programs for patients with chronic LBP in a  work-related  setting  had  been  relatively efficacious in comparison to other treatments or placebo or control groups which were kept on hold. More than a decade has passed since the last thorough analysis on this topic, and  new  studies  as  well  as  new guidance on conducting systematic reviews in the pain field have been published. More recent reviews that contain studies on back schools exist, although they are also now antiquated or are not thorough, for example, because they are geographically limited¹¹.

Hence, the present study was done with the objective of comparing the short-term  effects  of  lumbar stabilization exercises and back school programs and finding a better approach  in  clinical  practice  for  sub- acute and chronic nonspecific low back pain.

Objective of the study

To compare the effect of lumbar stabilization exercises and back school program for sub-acute and chronic non-specific low back pain

Hypothesis

Null Hypothesis(H0)

There is no significant effect of Lumbar stabilization exercises on sub-acute and chronic non-specific low back pain.

There is no significant effect of Back School Program on sub-acute and chronic non-specific low back pain.

There is no significant effect of both Lumbar Stabilization Exercises and Back School Program on sub-acute and chronic non-specific low back pain.

Research Hypothesis(H1)

There is significant effect of Lumbar stabilization exercises on sub-acute and  chronic  non-specific  low  back pain.

There is significant effect of Back School Program on sub-acute and chronic non-specific low back pain.

There is significant effect of both Lumbar stabilization exercises and Back School Program on sub-acute and chronic non-specific low back pain.

REVIEW OF LITERATURE

1. K. Kotteeswaran, S. Sahiya Anjum, et al. :- conducted a study to compare the effects of Lumbar Stabilization Exercise (LSE) versus conservative  treatment  in  healthcare  professionals  with  chronic low back pain (LBP). The study utilized convenient sampling and grouped 15 subjects for LSE with IFT (Interferential Therapy) and 15 for conservative  treatment  with  IFT.  Outcome  measures  included NPRS (Numeric Pain Rating Scale)  and  Modified  Oswestry  Low  Back  Pain  Disability  Questionnaire. The treatment duration was 4 weeks. The study concluded that LSE with IFT was more effective than conservative management with IFT in managing LBP among healthcare professionals. International Journal of Current Research and Review 2022;14(8):36-39.

2. Hye Jin Moon,  MD,  Kyoung  Hyo  Choi,  MD,  et  al.  :- conducted  a  comparative  study  on  patients with chronic non-specific low back pain. They compared lumbar stabilization exercises (LSS) with dynamic lumbar strengthening exercises. Randomization was  employed,  with  11  participants  in  the LSS group and 10 in the dynamic strengthening  group.  The  exercises  were  performed  for  1  hour, twice a week, over 8 weeks. Outcome measures included VAS, ODQ, and lumbar extensor strength at various angles ranging from 0° to 72°. The study concluded that LSS  was  more  effective  in strengthening lumbar extensors and improving functional outcomes in patients. Annals of Rehabilitation Medicine 2013;37(1): 110-117.

3. Jaza Rizvi, Neelum Zehra et. al.:- conducted a study at Dr.  Ziauddin  Hospital,  to  compare  two different exercise approaches on non-specific low back pain (LBP) among 30 occupational therapists. The participants were divided into two groups: Group A received lumbar stabilization exercises, while Group B underwent general extension exercises. The researchers used the Numeric Pain Rating Scale (NPRS) and Oswestry Low Back Pain Disability Questionnaire as outcome measures. The results of the study showed that lumbar stabilization exercises proved to be more effective than general extension exercises in reducing low back pain among occupational therapists. Pakistan Journal of Rehabilitation 2019;8(1): 43-48.

4. Esha A. Bhadauria and Peeyoosha Gurudut :- conducted  a  study  to  see  the  efficacy of  three different forms of exercises namely, LSS, Dynamic Strengthening, and Pilates in treating chronic non- specific low  back pain. The study included a total of 44 randomly assigned subjects who participated in 10 exercise sessions over a period of three weeks. IFT and HMP were used as conservative treatment for all groups. To evaluate the effectiveness of the interventions VAS, Oswestry Disability Questionnaire, Schober’s test, and pressure biofeedback were used. The findings of the study indicated that the LSS group demonstrated significant improvements across all outcome measures.Journal of Exercise Rehabilitation 2017;13(4):477-485.

5. Mehdi Pakbaz, Mohammad  Ali  Hosseini  et.al.  :-  conducted a study In iran on Effectiveness of the back school program on the low back pain and functional disability of Iranian nurse. Low back pain (LBP) as a recurrent and costly health problem and one of the leading causes of disability, is common in nurses. It can have adverse effects on the quality of life of nurses and quality of care of patients. The aim of the study was to evaluate the effectiveness of Back School program  on  the  LBP  and functional disability of Iranian nurses. A  quasi-experimental  methodological  design  was  utilized  for this study. Participants were nurses with back pain who participated in the Back School program workshop and completed a self-report visual analogue scales and  Roland–Morris  Disability questionnaire that measuring LBP and functional disability. Data were analyzed descriptively and comparisons in LBP and functional disability made between groups with t-test for pre-intervention and analysis of covariance for after intervention. Sixty-four participants (16 males, 48 females) completed this survey. The study participants’ mean age was 38.9± 8.1 years in intervention group and 38.1± 8.2 in control group. There were no significant differences in  terms  of  pain  (P=  0.575)  and  disability scores (P= 0.844) before intervention. Although, the intervention led to a decrease in the functional ability and LBP scores of the nurses (P< 0.001) in the intervention group compared with that in the control group. Overall, Back School program as an educational strategy can reduce the  LBP  and functional disability in nurses. This program can be suitable for preventing of pain and functional disability among nurses working in hospital settings. Journal of exercise rehabilitation 2019 Feb; 15(1): 134–138.

6. Patricia Thurow Bartz et. al. :- conducted a study on Effectiveness of the back school program for the performance of activities of daily living in users of a basic health unit in Porto Alegre, Brazil. In this study, the effects of Back School on pain, functionality, and the performance of activities of daily living (ADL) in users with chronic musculoskeletal pain were evaluated. [Subjects and Methods] Forty- four users (33 females and 11 males) participated in Back School, with five two-hour theoretical and practical meetings held once a week. The assessment instruments used were as follows: (a) a circuit evaluation of posture dynamics recorded on video, (b) an observational instrument of ADL using video, (c) anamnesis, (d) the visual analogue scale, and (e)  the  Oswestry  Disability  Index.  [Results]  The results showed decreased pain intensity, improved functionality, and the  recovery  of  ADL. [Conclusion] The Back School program is an effective health education strategy for users with chronic musculoskeletal pain. Journal of Physical Therapy Science 2016 Sep; 28(9): 2581–2586.

7. M W Heymans,  R  Esmail  et.al.  :-  conducted a study on Back schools for non- specific low back pain. The objective of this systematic review was to assess the effects of back schools for patients with non-specific low back pain. Only randomized trials that reported on any type of back school for non- specific low back pain were included. Fifteen RCTs were included in systematic review. Overall, the methodological quality was low. Only 3 trials were considered high quality. It was not possible to make relevant subgroup analyses for radiation versus no radiation or to have a relevant subgroup of studies reporting on acute low back pain only. The results indicate that there is moderate evidence that back schools have better short-term effects than other treatments for chronic low back pain, and that there is moderate evidence that back schools in an occupational setting are more effective compared to 'placebo' or waiting list controls. Spine 2005; 30(19):2153-2163.

8. Thayna Maria Jose, Clemente  da  silva  et.  al.  :- conducted a study to evaluate the effects of back school components in relieving pain and to improve quality of life on patients with chronic back pain.Forty-one patients were randomized and into four groups: (i) a back school group (educational lessons and physical exercise); (ii) an educational lessons group; (iii) a physical exercise  group  and  (iv)  a waiting list control group. Patients were evaluated before and after treatment with a visual analogue scale, a short form quality-of-life questionnaire, a Roland Morris disability questionnaire and a finger- floor distance test. The back school group showed  significant  reduction  in  scores  in  the  visual analogue scale and the Roland Morris disability questionnaire and an  increase  in  the  short-  form quality of life questionnaire. The effectiveness of back  school programs in chronic back pain patients seems to be due to the physical exercise component and not on account of the educational lessons. ConScientiae Saúde, 2014;13(4):506-515.

9. Megan Davidson, Jennifer L Keating et. al. :- conducted a study to examine 5 commonly used questionnaires for assessing disability in people with low back pain. The modified Oswestry Disability Questionnaire, the Quebec Back Pain Disability Scale, the Roland-Morris Disability Questionnaire, the Waddell Disability Index, and the physical health scales of the Medical Outcomes Study 36-Item Short- Form Health Survey (SF-36) were compared in  patients  undergoing  physical  therapy  for  low  back pain. This research involved 106 individuals suffering from low back pain who completed questionnaires during their initial visit to a physical therapist and again six  weeks  later.  The  study aimed to assess the reliability and responsiveness of these questionnaires in measuring changes in patients' conditions. It was found that the measurements obtained from  the  modified  Oswestry Disability Questionnaire, the SF-36 Physical Functioning scale, and  the  Quebec  Back  Pain  Disability Scale were the most dependable and had a wide enough range to consistently detect improvements or deteriorations in most patients' conditions. On the other hand, the Waddell Disability Index had a moderate level of reliability, but it was not considered suitable for practical clinical use due to certain limitations. Meanwhile, the Roland-Morris Disability Questionnaire and  the Role Limitations–Physical and Bodily Pain scales within the SF-36 were found to be lacking in terms of both reliability and the range they covered, making them less suitable for clinical applications. Physical Therapy 2002; 82(1):8-24.

10. Childs JD, Piva SR et. al. :- conducted cohort study to examine the responsiveness characteristics of the numerical pain rating scale (NPRS) in patients with LBP using a variety  of  methods. Determination of change on the NPRS during 1 and  4  weeks  was  examined  by  calculating  mean change, standardized effect size, Guyatt Responsiveness Index, area under a receiver operating characteristic curve, minimum clinically  important  difference,  and  minimum  detectable  change. Change in the NPRS from baseline to the 1 and 4-week follow-up was compared to the average of the patient and therapist's perceived improvement using the 15-point Global Rating of Change scale. They concluded that Clinicians can be confident that a 2-point change on the NPRS represents clinically meaningful change that exceeds the bounds of measurement error. Spine 2005; 30(11):1331-1334.

The study was conducted at the Department of Physiotherapy,  Dr.  B.  R.  Ambedkar  Medical  College  and Hospital in Bangalore, using a quasi-experimental design. A total of 20 participants were selected using a convenient sampling method, with strict inclusion and exclusion criteria  applied.  The  participants  were assigned to either group A (receiving lumbar stabilization treatment) or group B (receiving in back school program). Both groups received conservative treatment, including interferential therapy (IFT) and moist heat therapy, over a course of 10 sessions. This design allowed us to assess the specific  impact  of  Lumbar Stabilization Exercises and the Back School Program in addition to the standard care provided.

Inclusion Criteria

• Both male and female aged 25-50 years
• Non-specific low back pain (>2 months)
• NPRS >= 6

Exclusion Criteria

• Spinal fractures
• Degenerative changes and tumors
• Subjects with neurological involvements
• Bone disorders
• Systemic disorders

Outcome Measures

• Numerical Pain Rating Scale
• Quebec back pain disability scale
• ROM will be measured

Experimental Procedure-

Lumbar Stabilization Exercises

• Superman Pose
• Knee to Chest
• Bridging
• Lumbar Rotation
• Pelvic Tilt
• Sit-Ups

Back School Program

• Knee Up
• Standing Quadricep Stretching
• Cat and Camel
• Abdominal Hollowing
• Bird Dog
• Lying Hamstring Stretch

The comparison was done by making a group of 10 each. Where they received  LSE  or  BS  along  with conservative treatment for patients suffering from sub-acute and chronic non-specific LBP patient. We have included patients meeting the inclusion criteria and the outcome measures used is QBPDS, NPRS and lumbar ROM was measured.

Statistical Analysis

The collected data were tabulated and analyzed using descriptive and interferential statistics. Paired t-test is used to analyses significance between pre and post-test values and unpaired t-test was used  to  analyse significance between two groups. P value <0.05 was considered as statistically significant.

	Group – A (n=10) Mean ± SD.	Group – B (n=10) Mean ± SD.
Age (years)	40.2 ± 6.27	40.4 ± 2.97
Gender	5 Males 5 Females	5 Males 5 Females

 

Table 1. Demographic Characteristics