brummittLow back pain (LBP) is one of the most challenging musculoskeletal conditions to treat. Rehabilitation professionals have many tools available at their disposal; however, some examination and treatment techniques have not been investigated for their efficacy. The purpose of this blog is to highlight new research and novel approaches related to assessment and exercise prescription to patients with LBP that may help guide practice.

Back pain is a common musculoskeletal condition experienced by nearly 30% of the population each year.1 Billions of health care dollars are spent annually on medical tests (as well as treatments) for patients with back pain; however, many of the medical tests performed do not provide information that can positively impact practice.2,3 There are numerous conservative treatment options available to physical therapists (and other rehab professionals) who treat patients with back pain; however, despite best efforts some patients continue to experience pain and loss of function. There is need for continued research into how we assess and treat patients with back pain.

In 2014, Ganesh et al published Efficacy of the Star Excursion Balance Test in Detecting Reach Deficits in Subjects with Chronic Low Back Pain (published in Physiotherapy Research International).4 The purpose of their study was to assess performance on the Star Excursion Balance Test (SEBT) in individuals with chronic low back pain (CLBP). The utilization of the SEBT with this population is unique; the SEBT has been primarily utilized in athletic populations.

Figure 1. Star Excursion Balance Test: Anteriomedial Reach

Figure 1. Star Excursion Balance Test: Anteriomedial Reach

The Star Excursion Balance Test

The SEBT is a functional performance test that has been traditionally used to assess recovery from lower extremity injury and to identify athletes who may be at risk for a sports related injury. Figure 1 illustrates an individual balancing on his right lower extremity while performing an anteriomedial reach. The “star” shape of the SEBT is created by cutting four 6-ft to 8-ft strips of athletic tape. Two strips of tape are affixed to the floor to form the shape of a “+”. The other two strips are placed on the floor oriented at 45° angles to the original “+” strips (Figure 2).

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The test is performed by having the subject (patient or client) stand in the center of the star with the malleoli on the stance leg aligned with medial-lateral axis. The rehabilitation professional instructs the patient/client to reach as far as possible in a direction (e.g., one of the 8 arms of the “star”) while maintaining balance with her/his stance leg. The individual is not allowed to bear weight with the reach leg, rather she/he should only briefly touchdown with the front portion of the foot. The point where the patient/client touches along the length of the tape is marked with the reach distance measured from the center of the star.

As previously mentioned, the SEBT has been used in rehabilitation and to assess future risk of injury in athletes. For example, in a rehabilitation setting, the SEBT could be used to assess for asymmetry in reach performance between lower extremities in the patient with a lateral ankle sprain. Asymmetry in reach distance, usually when weight-bearing on the injured lower extremity, may be due to pain or impaired proprioception. The clinician would typically reassess a patient’s performance on the SEBT in order to assess the effectiveness of a treatment program and to help guide discharge from therapy.

SEBT and Chronic Low Back Pain

Recent research from Ganesh et al.4 has presented a novel use for the SEBT. As previously mentioned, the SEBT has been primarily used as a tool to assess functional movement performance in individuals after lower extremity injury. Ganesh et al. elected to assess SEBT performance in subjects with chronic low back pain (CLBP). They recruited 20 subjects; 10 with history of low back pain of at least 6 months and 10 healthy subjects. The individuals in each group were similar for age and gender. Reach performance with the non-dominant leg in each of the 8 directions was measured for all subjects.

The researchers found that subjects with CLBP had significantly lower reach distances in 7 out of 8 directions when compared to the subjects in the control group. The only direction where the groups were similar was in the posterior reach. The authors suggest that the SEBT could be used as an assessment to measure balance in posture in patients with CLBP.

Clinical Relevance

FigureIII

Figure 3

Whenever we review research we should ask the question “how does (or could) this impact practice?” As previously mentioned, this research is novel in that the authors explored SEBT measures in individuals with CLBP; however, the findings are what we would likely expect. There are numerous research studies related to performance measures (e.g., range of motion, strength tests, etc) comparing individuals with CLBP and controls. How could the SEBT be utilized in a treatment program for a patient with CLBP? Ultimately that question would need to be answered through research. I propose that the SEBT could be used for assessment of reach performance followed by therapeutic exercises targeting one’s deficits. There is some evidence suggesting that a global (or general) exercise approach can help reduce pain in individuals with low back pain.5 Figure 3 illustrates an example of a functional (general) exercise performed on the star. When a patient performs an exercise, such as a lunge with trunk rotation (Figure 3), on the star she/he is able to receive immediate feedback regarding functional improvements. Whether or not performance of therapeutic exercises on the star leads to reductions in pain is yet to be determined. More clinically relevant research is warranted.

References

  1. Center for Disease Control and Prevention. Severe headache or migraine, low back pain, and neck pain among adults aged 18 and over, by selected characteristics: United States, selected years 1997-2012. 2013. Available at: http://www.cdc.gov/nchs/data/hus/2013/048.pdf. Accessed March 15, 2015.
  2. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002; 137(7): 586-597.
  3. Jensen MC, Kelly AP, Brant-Zawadzki MN. MRI of degenerative disease of the lumbar spine. Magn Reson Q. 1994; 10(3): 173-190.
  4. Ganesh GS, Chhabra D, Mrityunjay K. Efficacy of the star excursion balance test in detecting reach deficits in subjects with chronic low back pain. Physiother Res Int. 2014; [Epub ahead of print].
  5. Brumitt J, Matheson JW, Meira EP. Core stabilization exercise prescription, part 2: a systematic review of motor control and general (global) exercise rehabilitation approaches for patients with low back pain. Sports Health. 2013; 5(6): 510-513.