@2024 Afarand., IRAN

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ISSN: 2008-2630    Iranian Journal of War & Public Health 2018;10(1):47-52

Background
After an amputation surgery, the body's structure changes and a variety of kinetics and kinematics changes can be found in the amputee compared to the healthy people [1, 2]. … [3-6]. Asymmetry during walking in people with lower limb amputation leads to asymmetry in muscle activity (muscle recall and morphology) and ultimately leads to fatigue and instability in the spine and low back pain [7].
Previous Studies
Several studies have shown changes in the multifidus muscle cross-section in people with low back pain [8-12]. … [13-15]. According to a study, the severity of back pain is associated with asymmetry of multifidus muscle in the lower knee limb amputees [16]. … [17, 18]. Daniel et al. have shown that exercises for movement control, cross-section and function increase the stabilization of this muscle and reduce the amount of atrophy of lipid in the multifidus muscle and low back pain [19]. Akbari et al. have also shown the positive effect of two types of exercises on multifidus muscle thickness [20]. It has been shown in the research that stabilizing exercises affect muscle symmetry of the multifidus on the affected side and the other side [21]. Exercise improves the hypothyroid level by reducing the asymmetry [22]. … [23-26].
Aim(s)
Lower back pain in people with amputation is more likely to result from motion asymmetry than degenerative changes. Therefore, exercises are needed in the context of corrective exercises. The corrective exercises target the Myofascial using the foundations of the academy of sport medicine, and include all four-part exercises for the release of myofascial, tension, activation and integration [27]. The aim of this study was to investigate the effect of a 12-week course of corrective exercises on the pain intensity and asymmetry of the lumbar multifidus muscle in veterans with one-sided below-knee amputation suffering from chronic low back pain.
Research type
This is a quasi-experimental study with pretest and posttest design.
Research society, place and time
This research was conducted among male veterans with one-sided under-knee amputation of the Kosar Center of Orthosis and Prosthesis in Tehran in 2016.
Sampling method and number
In a voluntary sampling method, 20 of 175 veterans with under-knee amputation who had participated in the need assessment of health of veterans with unilateral amputation under the knee were selected who were diagnosed with chronic low back pain by an orthopedic surgeon and physician. These people participated in the study by completing the consent form. Inclusion criteria included low back pain for 12 weeks or more, continued use of prosthesis during the past year, no history of surgery in the past 2 years, and the person's desire to exercise. Exit criteria also included the presence of Red Flag in the evaluation of low back pain according to the opinion of two physicians, and a significant change in the health status of these individuals (leading to extensive intervention or surgery).
Used devices&materials
Measuring the severity of low back pain was performed using Visual Analog Scale by numerical grading of 0 to 10. The severity of pain during research and the worst pain situation were evaluated in the last 3 months. The reliability of the pain intensity score has been mentioned as 0.91 and it has been confirmed [28]. Evaluation of muscle asymmetry was performed by maximum voluntary contraction of multifidus muscles with manual resistance to extension of trunk and evaluation of muscle endurance with Sorensen test. During the assessment of muscular asymmetry, people were placed on the bed and attempted to open the spine against the resistance exercised by the examiner. In the Sorenson test, people were placed on the bed lay on their abdomen in the way that their trunk was suspended and they were trying to achieve a horizontal state and maintain it [29]. Each of the trails was performed up to 3 times with a 30-second rest in order to relieve fatigue, and finally, the best test record was cited. The validity and credibility of this test have been confirmed in the measurement of trunk right muscle endurance and its reliability has been reported to be 88% in patients with low back pain [30]. In order to record the electrical activity, the electrodes were placed on the surface of the multifidus muscle at the amputation and healthy side (2 centimeter out of the lumbar spine) [31]. The reference electrode was placed on the ulna osteoid bone graft. Electromyography was recorded using 8-channel wireless V8.24 (EMG BayaMed, Iran) and F-55 electrodes (Skintact, Austria). The 1000 Hz sampling rate, analogue to digital conversion with a 16-bit A/D converter and filter of 20 to 490 Hz were performed. Data analysis was performed in Lab View using BayaMed analysis software. The root mean square (RMS) was considered as the most significant signal strength measurement. The symmetry coefficient of activity of the multifidus muscle on the healthy and amputee side were calculated using related formula. The asymmetry coefficient near zero is indicative of a lack of asymmetry and close to 100 is sign of high asymmetry [32]. After initial evaluation of the subjects including the intensity of back pain using numeral grading and surface electromyography, the selected exercises were taught to subjects in person. The training materials including a training brochure and training video were delivered to people instructed to carry out the exercises at home in accordance with the predictions and plans. A follow-up form was provided to record the course of the exercise. To control and respond to any questions, they were contacted weekly by phone call. There was a possibility of daily telephone contact with clinical guides. The training program included exercises of 5 days a week, a 3-month training course for corrective exercises. In the first two weeks, myofascial release exercises were performed. From the third week, along with myofascial training, stretching exercises began. So that the person first performed the release exercises and then followed the tensile exercises. From the seventh week, reinforcement and integration training was added to the previous exercises, and continued until the end of the 12th week (Table 1). The assessment of the intensity of back pain and surface electromyography was measured again at the end of the training period. Data were analyzed by SPSS 20 software by Kolmogorov-Smirnov test to verify the normal distribution of data and dependent t-test was used for examining changes in pain and symmetry coefficient.
Findings by Text
The mean age of subjects was 52.15±5.50 years and averagely 27.35±8.9 years had been passed from the amputation of the veterans. Veterans had a mean low back pain score of 6.40±2.90 in the three months. The severity of pain was significantly lower than the pretest and a significant increase was observed in the maximum contraction of the lumbar multifidus muscle in the amputation side of the subjects in the posttest compared to the pretest. These exercises did not have any significant effect on muscle asymmetry of multifius in maximal muscle contraction and muscular endurance (Table 2).
Main comparison to the similar studies
… [33, 34]. The research by Hydez et al. has shown the effect of 4 weeks of stabilizing exercise on the rapid increase in the cross-section of multifidus muscle [34] which was consistent with this study. Despite pain relief and increase muscle strength in the amputation side, these exercises did not show a significant effect on the maximum multifidus muscle contraction of healthy side. These findings were consistent with the results of Wilmink et al. that the clinical improvement is not due to anatomical changes in the muscle. According to them, exercises have an effect on the central nervous system, not just an environmental effect [35]. … [36-44]. The findings of this study showed that exercises did not have a significant effect on muscle asymmetry of multifidus muscle. These results are contrary to the research of Pleustrine et al. They have described the positive effects of various types of home-based and therapeutic exercises on the symmetry of lumbar muscles [45]. This difference can be attributed to the studies in which the subjects were not amputees. Based on a research of the effects of exercises on low back pain in people with amputation, the only anaphorculo study was found in upper limb amputation. In this research, Back School exercises were trained to a group of people and others were given educational materials. In the evaluation after 3 months, recovery of pain was seen in all people. In this study, surface electromyography had not been used [46]. … [47-49].
Suggestions
It is suggested that more extensive research be done on the effect of exercise with a longer period of time.
Limitations
The limitation of this study was the lack of comparison and evaluation of data with a control group.
Conclusions
Selective corrective exercises have a positive effect on severity of pain in male veterans with one-sided under-knee amputation suffered from chronic low back pain. However, they did not have any effect on multifidus muscle asymmetry in maximal muscle contraction and muscular endurance.
Acknowledgments
We are grateful to all the friends who helped us in this research, as well as the great veterans who participated in this study.
Conflict of interest
Non-declared
Ethical Permissions
The Ethics Committee of Biomedical Research Committee of the Foundation of Martyrs and Veterans Affairs endorsed this research with code 95-E-D-103. For the subjects in the research, the consent form was distributed and collected. Information about people was kept confidential.
Funding Sources
The cost of this project has been provided by Veterans Medical and Engineering Research Institute.

TABLES and CHARTS

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