Combination of Electrical Stimulation and Motor Control Exercise for Chronic Nonspecific Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

  


    
study

    
intervention group

    
control group

    
ES

    
MCE

    
other intervention

  

  


    
types

    
duration

    
location

    
stimulation

    
types

    
duration

    
movements

  

  


    
Akhtar, M. W., et al. (2017)28

    
1.CSE Group + TENS + therapeutic ultrasound

    
1.Routine Physical Therapy + TENS + therapeutic    ultrasound

    
TENS

    
10 minutes

    
lumbar spine

    
Continuous mode

    
CSE

    
Last 40 minutes with 


      5-10 minutes rest interval, twice a week at home for up to six weeks

    
Hamstring stretching


      Calf stretching 


      Hip flexors stretching


      Back extensors stretching 


      Abdominal curl-up exercise in supine


      Back extensors exercise in prone


      Hip extensors exercises in prone

    
therapeutic ultrasound


      (3MH for 10 minutes at 50% intensity)

  

  


    
Alrwaily, M., et al. (2018)30

    
1.Stabilization exercises program supplemented    with NMES

    
1.Stabilization exercises program only

    
NMES

    
20 minutes at first

    
the lumbar paraspinal muscles bilaterally

    
pulse frequency of 75 pulses per second, a pulse    duration of 250s,


      with a 4-s ramp up and ramp down time, and a 6-s stimulation period at the    maximum amplitude, followed by a 50 s rest period to minimize fatigue

    
Stabilization Exercises

    
20 minutes

    
abdominal bracing exercises, 


      side support exercises


      quadruped exercises

    
NA

  

  


    
Atli, E., et al. (2021)12

    
1.NMES simultaneously applied with CSE

    
1.sham NMES and CSE

    
NMES

    
35 minutes

    
paravertebral muscles bilaterally at 


      the level of L4-5 spinous

    
the first 2 minutes (warming up phase), frequency    is 6Hz. Contraction phase includes consecutive cycles of contractile    frequency of 40Hz for 6 seconds and the rest frequency of 4Hz for 12 seconds,    lasting a total of 30 minutes. The last 3 minutes (recovery phase) frequency    is 3Hz. The 


      ramp up time is 2 seconds and the ramp down time is one second.

    
CSE

    
10 times of 12 sessions

    
abdominal bracing exercises in supine, prone and    quadruped positions, bridge, crunch and plank

    
NA

  

  


    
Durmus, D., et al. (2009)25

    
1.ES program and exercises


      2.US treatment and exercises

    
1.only exercises

    
ES

    
15 minutes

    
the second lumbar vertebrum to fourth lumbar    vertebrum levels over the erector spinae muscles bulks motor points

    
The symmetric biphasic wave was applied with the    frequency of 50 Hz and 50 ms of phase time. The intensity of the current was    arranged separately one by one for each patient until apparent muscle    contraction was established (60–130 mA). The stimulation


      was applied as 10 s of contraction and 10 s of relaxation

    
exercises

    
45 minutes,3 days a week

    
1. Motion, Flexibility, and back strengthening    exercises of the cervical, thoracic, and lumbar spine; stretching of the    erector spine muscle, hamstring muscles, pelvic muscles, and abdominal    muscles: (1) pelvic tilt, (2) knee to chest, (3) lower abdominal exercises,    (4) cat and camel, (5) back extension exercises. 


      2. Special exercises to correct mobility of the spine and hip joints,    activate the stabilizing muscles of the spine, and increase flexibility of    the lower limb muscles. 


      3. Functional exercises to improve postural control, dynamic body balance,    and coordination. 


      4. Progressive relaxation exercises to normalize muscle tension.

    
US: using Enraf Nonius Sonoplus that operated at    1 MHz frequency and 1 W/cm2 intensity and a transducer head with an area of 5    cm, an ERA of 4 cm, and a BNR of 1:5. Slow circular movements were applied by    the transducer head over the paravertebral low back region. The treatment    duration was 10 minutes.

  

  


    
Embaby, E. A., et al. (2021)24

    
1. LFPCs + lumbar stabilization exercises


      2. RC + lumbar stabilization exercises

    
1.only lumbar stabilization exercises

    
NMES

    
20 minutes at first

    
located bilaterally at an interelectrode 


      spacing of approximately 2 cm on a cross-line drawn on L4-5 interspinous

    
LFPCs: a constant current and asymmetrical    biphasic waveform and Biphasic symmetrical pulses of 200 μs with an    interpulse delay of 100 μs were employed;50 Hz; contraction for 500 μs    and relaxation for 19 ms


      RC: 2500-Hz alternating current, applied in 50-Hz rectangular bursts with a    burst duty cycle of 50%. The burst duration is 10 ms at 50 Hz. The other is    same as the LFPCs.

    
lumbar stabilization exercises

    
15–20 minutes,2 times per day

    
abdominal bracing exercises


      side support exercises


      quadruped exercises

    
NA

  

  


    
Franco, K. M., et al. (2016)17

    
1.IFC Active + Pilates

    
1.IFC Placebo + Pilates

    
IFC

    
30 minutes in first two weeks

    
at the site of pain

    
IFC was applied with bipolar (pre-modulated)    application with two channels under medium-frequency alternating currents,    the current's amplitude was increased until the participant reported a strong    but comfortable tingling sensation, and this procedure was repeated every    five minutes.

    
Pilates

    
additional 40 minutes in the last four weeks

    
Initially the patient was trained to contract    isometrically the powerhouse muscles (e.g. transversus abdominis, multifidus,    and pelvic floor muscles) during exhalation and then was instructed to hold    this contraction during all exercises to stabilize the spine The level of    difficulty and the patient’s preferences in relation to the exercises were    individualized. Ten repetitions of each exercise were performed.

    
NA

  

  


    
Hicks, G. E., et al. (2016)29

    
1.TMT+NMES

    
1.Passive Control Intervention

    
NMES

    
15 minutes, twice


      weekly

    
lumbar paraspinals bilaterally (L2-L5)

    
deliver a 2500Hz, alternating current, modulated    at 50 bursts per second. The stimulus amplitude was increased to a minimum    level that resulted in a full, sustained, isometric contraction of the lumbar    paraspinals (no evidence of muscle fasciculations on visual 


      inspection) and then further increased to the subject’s maximum tolerance.    Stimulus on/off, time settings were10 seconds on and 60 seconds off. Each    participant received 15 electrically stimulated contractions of the lumbar    paraspinal muscles per treatment session.

    
TMT

    
30 minutes, twice weekly

    
Abdominal Bracing in supine


      Bracing in hook-lying with leg movements


      Bracing in hook-lying with bridging


      Abdominal Bracing in standing


      Single arm or leg lifts-standing with elbows leaning on counter


      Opposite arm and leg lifts standing with elbows on counter 


      Single arm or leg lifts-prone over bolster


      Opposite arm and leg lifts-prone over bolster


      Same exercises performed in quadruped


      Curl ups 


      Remedial side bridge against wall 


      Remedial side bridge with leg lift on floor/bed 


      Horizontal side bridge

    
Passive control group lasts 40-45 minutes,    including 20 minutes of moist heat to their lower back, 7 minutes of    sub-therapeutic ultrasound (continuous pulse, 25 watts/cm2) to the lumbar    paraspinal region, 8 minutes of light effleurage massage to the thoracolumbar    region and 5 minutes of upper extremity stretching exercises focused on the    shoulder girdle and upper back

  

  


    
Kim, T. H., et al. (2014)26

    
1.CES+ standard treatment

    
1.the standard treatment

    
TENS

    
20 minutes

    
NA

    
NA

    
CSE

    
30minutes, five times per week

    
The CORE program consists of 14 exercises (head    to toe prep, tongue stretch, belly blaster, belly breath, the cobra,    butterfly/heel beats comba, three part pelvic stabilizers, four-part    progressive hamstring stretch, double knee to chest, lying spinal twist,    belly breath, cross extension, the cobra, belly breath final) and indicates    specific trunk muscle activation.

    
15minute hot-pack 


      treatment

  

  


    
Mane, N. P., et al. (2019)27

    
1.Motor control training, HMP and TENS

    
1.Core muscle training, HMP and TENS

    
TENS

    
NA

    
NA

    
NA

    
MCE

    
NA

    
First week: 8 reps: (1) Activation of transversus    abdominis. (2) Activation of multifidus


      Second week: 15 reps, 5-10 sec hold:(1) Strengthening of transversus    abdominis. (2) Strengthening of Multifidus.

    
HMP

  

  


    
Straudi, S., et al. (2018)31

    
1.Real-tDCS+ group exercises

    
1.Sham-tDCS+ group exercises

    
tDCS

    
20 minutes

    
The location of the motor cortex was estimated    using the international 10–20 electroencephalogram system and placing the center of the electrode pad at the third or fourth cervical vertebra.

    
This continuous stimulation lasted 20minutes,    with an intensity of 2mA for five consecutive days

    
Group Exercise intervention

    
1 hour, 2~3 times a week

    
group exercises, including education,    strengthening exercise, stretching exercise, relaxation techniques

    
NA

  

  


    
ES: Electrical    Stimulation; MCE: Motor Control Exercise; CSE: Core Stabilization Exercise;    TENS: Transcutaneous Electrical Nerve Stimulation; NMES: Neuromuscular Electrical    Stimulation; NA: Not Available, L4-5: The Fourth Lumbar vertebrum and Fifth Lumbar    Vertebrum; US: Ultrasound; LFPCs: Low-Frequency Pulsed Currents; RC: Russian Current;    IFC: Interferential Current; TMT: Trunk Muscle Training; HMP: Hot Moist Pack,    tDCS: Transcranial Direct Current Stimulation 

  

  


    
 

  

Table 2: Summary of Included Studies in the Meta-Analysis (Intervention).