Original Article |
Corresponding author: Trupti B. Mehta ( drtrupti_1507@yahoo.co.in ) © 2024 Trupti B. Mehta, Amit Sharma.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Mehta TB, Sharma A (2024) Lower cross syndrome: specific treatment protocol versus generalized treatment protocol. A randomized single-blinded trial. Folia Medica 66(5): 662-672. https://doi.org/10.3897/folmed.66.e135838
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Introduction: Lower crossed syndrome (LCS) is a biomechanical muscle imbalance causing low back pain.
Aim: This study aimed to compare specific treatment protocols versus generalized treatment protocols for managing low back pain associated with LCS.
Materials and methods: This randomized, single-blinded trial involved 200 patients (aged 20-40 years) with low back pain and LCS. Patients were divided into four groups: A1 and A2 (specific protocols for posterior and anterior LCS), and B1 and B2 (generalized protocols). Interventions were administered thrice weekly for two weeks. Outcome measures included Numerical Pain Rating Scale (NPRS), Modified Oswestry Disability Questionnaire (MODQ), Lumbar Lordosis Index (LLI), abdominal and gluteal muscle strength, and iliopsoas and back extensor flexibility.
Results: All groups showed significant improvements in all parameters (p<0.01). However, specific protocols demonstrated superior outcomes. Group A1 showed the greatest reductions in pain (median NPRS decrease: 5), disability (median MODQ decrease: 45), iliopsoas tightness (median decrease: 12°) and back extensor tightness (median decrease 6.5). Group A2 exhibited the highest improvements in abdominal strength (median increase: 8 kg) and gluteal muscle strength (median increase: 8 kg).
Conclusion: Specific treatment protocols were significantly more effective than generalized protocols in managing low back pain associated with LCS. These findings emphasize the importance of accurate LCS classification and tailored interventions for optimal therapeutic outcomes in patients with low back pain.
lower crossed syndrome, low back pain, muscle imbalance, physiotherapy specific treatment
In the modern era, every individual lives a busy life putting stress on their body which is considered trivial by human nature. This stress over some time rises to a level where it presents as pain primarily in the lower back region.
Non-specific low back pain is defined as low back pain not attributable to a known cause.[
There are several factors that are responsible for the development of low back pain which includes increased lumber lordosis, reduced abdominal muscle length and strength, reduced endurance of back extensor muscle, back extensor muscle flexibility, length of the iliopsoas, hamstring muscle flexibility, and body composition.[
The lower crossed syndrome (LCS) is defined an “S” shaped posture of the lower back region characterized by weak abdominal muscle and gluteus maximus muscle paired with tight hip flexors and lower back muscles. It is also referred to as a distal or pelvic crossed syndrome.[
Low back pain (LBP) leads to impaired motor performance and causes difficulty in performing daily activities. It is a universal problem and lower crossed syndrome (LCS) is one of the conditions of biomechanical muscle imbalance due to extreme stress that is placed on the structures of the lower back. People with such postural imbalance often complain of lower back pain and when left untreated, this postural imbalance can lead to chronic lower back pain that becomes more difficult to correct.
There is a lack of literature, which shows the specific physiotherapy management for patients with type A and type B (predominant) lower crossed syndrome.
Hence, this study was designed to compare the specific treatment protocol versus generalized treatment protocol on pain and disability in low back pain with lower cross syndrome patients. It may provide appropriate corrective management of the specific affected musculatures. If it can be managed at an early stage, it will serve as a further prevention strategy in preventing the risk of developing chronic LBP.
This is an interventional, randomized, single-blinded trial conducted at Rajkot, Gujarat, India on 200 eligible patients. Ethical clearance was obtained from the institutional ethics committee (human), PDU Medical College, Rajkot, vide reference number PDUMCR/IEC/19/2022, and a clinical trial registry was done for the study vide reference number CTRI/2022/07/044487. Written informed consent was obtained to participate in the study and use the data for research and educational purposes. The study was carried out according to the principles of the Declaration of Helsinki (2013) and good clinical practice (GCP).
The sample size was calculated using mean and standard deviation (SD) values from both groups, aiming for a 95% confidence level and 80% power. This resulted in a total of 200 subjects, divided equally into experimental and control groups. Inclusion criteria encompassed patients of both genders, male and female, between ages 20 to 40 years, clinically diagnosed with low back pain <6 months and lower cross syndrome. Exclusion criteria included subjects with spondylolisthesis, lumbar canal stenosis, recent history of trauma or fall, neurological deficits, history of corticosteroid injections in preceding 3 months, history of previous lower limb, hip, pelvis, and spine trauma or fracture, and patients with any recent medical treatment or physiotherapy.
A total of 200 patients were taken for the study and were allocated randomly using the envelope method to control and experimental group. Then patients in group A and group B were further divided based on lumbar lordosis index into: group A1 which administered a specific treatment protocol for posterior lower cross syndrome (lumbar hyperlordosis group), group A2 which administered a specific treatment protocol for anterior lower cross syndrome (lumbar hypolordosis group), group B1 which was administered generalized treatment protocol for posterior lower cross syndrome (lumbar hyperlordosis group), group B2 which was administered generalized treatment protocol for anterior lower cross syndrome (lumbar hypo lordosis group). Normal values for lumbar lordosis index are 6.50–17.80.[
Group A1 (posterior lower cross syndrome) involved patients with lumbar hyperlordosis. The treatment combined stretching[
The data including the demographic characteristics and the outcome parameters – measured both before and after intervention in each group were recorded and analyzed using Microsoft Excel (Microsoft® Corporation, Redmond, WA). Appropriate statistical tests were used to check for statistical significance. A P-value <0.05 was considered statistically significant.
As can be seen by Table
Age groups | Group A1 (n=50) | Group A2 (n=50) | Group B1 (n=50) | Group B2 (n=50) | ||||
N | % | N | % | N | % | N | % | |
20-25 | 10 | 20 | 7 | 14 | 11 | 22 | 05 | 10 |
26-30 | 13 | 26 | 14 | 28 | 11 | 22 | 13 | 26 |
31-35 | 14 | 28 | 11 | 22 | 13 | 26 | 17 | 34 |
36-40 | 13 | 26 | 18 | 36 | 15 | 30 | 15 | 30 |
Fisher exact value=7.23, p=0.85 | ||||||||
Gender | Group A1 (n=50) | Group A2 (n=50) | Group B1 (n=50) | Group B2 (n=50) | ||||
N | % | N | % | N | % | N | % | |
Male | 21 | 42 | 25 | 50 | 23 | 46 | 25 | 50 |
Female | 29 | 58 | 25 | 50 | 27 | 54 | 25 | 50 |
χ2 =0.88, df=1, p=0.84 | ||||||||
BMI kg/m2 | Group A1 (n=50) | Group A2 (n=50) | Group B1 (n=50) | Group B2 (n=50) | ||||
N | % | N | % | N | % | N | % | |
<18.5 | 01 | 2 | 2 | 4 | 3 | 6 | 2 | 4 |
18.5–22.9 | 14 | 28 | 16 | 32 | 25 | 50 | 14 | 28 |
23–24.9 | 12 | 24 | 4 | 8 | 5 | 10 | 11 | 22 |
≥25 | 23 | 46 | 28 | 56 | 17 | 34 | 23 | 46 |
Fisher exact value=0.99, p=0.0011 |
Table
Comparison of outcome parameters (NPRS, MODQ, and lumbar lordosis index) within groups (N=200)
Group | Numerical pain rating scale (NPRS) | Wilcoxon signed rank test P-value | |||||||
Before intervention | After intervention | ||||||||
Median | IQR | Mean | SD | Median | IQR | Mean | SD | ||
Group A1 (n=50) | 7 | 2 | 6.9 | 1.01 | 1 | 1 | 1.42 | 1.05 | <0.01 |
Group A2 (n=50) | 7 | 2 | 6.72 | 1.08 | 2.5 | 1 | 2.5 | 1.29 | <0.01 |
Group B1 (n=50) | 6 | 2 | 6.14 | 0.99 | 4 | 2 | 3.78 | 1.31 | <0.01 |
Group B2 (n=50) | 7 | 2 | 6.64 | 1.13 | 3 | 2 | 3.32 | 1.44 | <0.01 |
Group | Modified Oswestry disability questionnaire (MODQ) | Wilcoxon signed rank test P-value | |||||||
Before intervention | After intervention | ||||||||
Group A1 (n=50) | 64 | 54-70 | 62.8 | 10.6 | 18 | 12-27.5 | 19.4 | 9.14 | <0.01 |
Group A2 (n=50) | 62 | 52-68 | 61.4 | 10.5 | 26 | 20-39.5 | 28.6 | 12.7 | <0.01 |
Group B1 (n=50) | 58 | 52-66 | 58.8 | 9.74 | 33 | 26-40 | 35.3 | 12 | <0.01 |
Group B2 (n=50) | 62 | 56.5-68 | 62.2 | 9.42 | 34 | 26-45.5 | 36.3 | 12.1 | <0.01 |
Group | Lumbar lordosis index | Wilcoxon signed rank test P-value | |||||||
Before intervention | After intervention | ||||||||
Group A1 (n=50) | 22.3 | 19.5-24.2 | 22 | 3.48 | 10.5 | 9.7-12.3 | 10.9 | 1.75 | <0.01 |
Group A2 (n=50) | 6.3 | 5.3-7.07 | 6.26 | 1.2 | 13.6 | 12.3-14.9 | 13.9 | 2.35 | <0.01 |
Group B1 (n=50) | 20.2 | 18.9-23.4 | 21.5 | 3.62 | 17.4 | 15.4-18.8 | 17.7 | 3.37 | <0.01 |
Group B2 (n=50) | 6.4 | 5.28-7.07 | 6.32 | 1.13 | 9.2 | 8.3-11 | 9.71 | 1.98 | <0.01 |
Comparison of outcome parameters (abdominal and gluteal strength, iliopsoas and back extensor tightness) within groups (N=200)
Group | Abdominal strength (Kg) | Wilcoxon signed rank test P-value | |||||||
Before intervention | After intervention | ||||||||
Median | IQR | Mean | SD | Median | IQR | Mean | SD | ||
Group A1 (n=50) | 4 | 3-5 | 4.38 | 1.32 | 7 | 6-8 | 7.26 | 1.55 | <0.01 |
Group A2 (n=50) | 2 | 2-3 | 2.42 | 1.11 | 10 | 9-12 | 10.3 | 1.62 | <0.01 |
Group B1 (n=50) | 4 | 3-4 | 3.5 | 1.34 | 5 | 3-5 | 4.26 | 1.41 | <0.01 |
Group B2 (n=50) | 3.5 | 3-5 | 3.54 | 1.39 | 5 | 4-6 | 4.78 | 1.42 | <0.01 |
Group | Gluteal muscle strength of right-left (Kg) | Wilcoxon signed rank test P-value | |||||||
Before intervention | After intervention | ||||||||
Group A1 (n=50) | 4 | 3-5 | 4.17 | 1.56 | 7 | 5.13-8 | 6.62 | 1.56 | <0.01 |
Group A2 (n=50) | 2 | 1.5-2.88 | 2 | 0.75 | 10.3 | 9-11 | 10.2 | 1.13 | <0.01 |
Group B1 (n=50) | 2.5 | 2-3 | 2.37 | 0.69 | 3.5 | 3-3.5 | 3.3 | 0.66 | <0.01 |
Group B2 (n=50) | 2.75 | 2.5-3 | 2.67 | 0.81 | 4.5 | 3.5-5 | 4.34 | 0.98 | <0.01 |
Group | Iliopsoas tightness of right-left side (degrees) | Wilcoxon signed rank test P-value | |||||||
Before intervention | After intervention | ||||||||
Group A1 (n=50) | 22 | 19.6-25 | 22.5 | 4.17 | 10 | 9-10.9 | 10 | 2.02 | <0.01 |
Group A2 (n=50) | 19 | 18-20 | 19 | 2.22 | 17 | 15-19 | 17 | 2.18 | <0.01 |
Group B1 (n=50) | 20 | 17.3-23 | 20.1 | 3.8 | 19 | 17-22 | 19.6 | 3.86 | <0.01 |
Group B2 (n=50) | 20 | 17.3-22.4 | 20.1 | 3.36 | 18.3 | 17-21 | 19 | 3.22 | <0.01 |
Group | Back extensor tightness (degrees) | Wilcoxon signed rank test P-value | |||||||
Before intervention | After intervention | ||||||||
Group A1 (n=50) | 5 | 5-6 | 5.36 | 1.08 | 12 | 10.3-13 | 11.8 | 1.53 | <0.01 |
Group A2 (n=50) | 5 | 4-6 | 4.98 | 0.97 | 6 | 6-7 | 6.24 | 0.89 | <0.01 |
Group B1 (n=50) | 5.5 | 5-6 | 5.38 | 1.1 | 6 | 6-7 | 6.2 | 1.03 | <0.01 |
Group B2 (n=50) | 5 | 4-6 | 5.02 | 1.22 | 7 | 6-7 | 6.56 | 1.09 | <0.01 |
Based on Table
Comparison of difference in outcome parameters (NPRS, MODQ, lumbar lordosis index, abdominal and gluteal strength, iliopsoas and back extensor tightness) between groups (N=200)
Difference in | Groups | Kruskal-Wallis test | |||||||
Group A1 (n=50) | Group A2 (n=50) | Group B1 (n=50) | Group B2 (n=50) | ||||||
Median | IQR | Median | IQR | Median | IQR | Median | IQR | P-value | |
NPRS | 5 | 5-6 | 4 | 4-5 | 3 | 2-3 | 3.5 | 3-4 | <0.01 |
MODQ | 45 | 34-52 | 28 | 22.5-43.5 | 21 | 12-32 | 25 | 18-30 | <0.01 |
Lumbar lordosis index | 10.9 | 9.13-12.8 | 7.7 | 6-9.2 | 2.9 | 2-4.38 | 3.1 | 2.1-4.5 | <0.01 |
Abdominal strength (kg) | 3 | 2-4 | 8 | 7-9 | 1 | 0-1 | 1 | 1-2 | <0.01 |
Gluteal muscle strength of right-left (kg) | 2.5 | 2-3 | 8 | 7.13-9 | 1 | 0.5-1.38 | 1.5 | 1.5-2 | <0.01 |
Iliopsoas tightness (degrees) | 12 | 10-15 | 2 | 1.13-2.5 | 0.5 | 0-1 | 1 | 0.5-1.88 | <0.01 |
Back extensor tightness (degrees) | 6.5 | 5-7 | 1 | 1-2 | 1 | 0-1 | 2 | 1-2 | <0.01 |
This study aimed to evaluate the effectiveness of specific treatment protocols compared to generalized treatment protocols for patients with low back pain associated with lower cross syndrome (LCS). The results demonstrate significant improvements in pain intensity, disability levels, and lumbar lordosis index across all intervention groups, with specific protocols showing superior outcomes.
All four groups experienced statistically significant reductions in pain levels as measured by the Numerical Pain Rating Scale (NPRS). However, the specific treatment protocols (groups A1 and A2) resulted in more substantial pain reductions compared to the generalized protocols (groups B1 and B2). Group A1, which received the specific protocol for posterior LCS/lumbar hyperlordosis, showed the greatest median reduction in NPRS scores (5 points), followed by group A2 (4 points).
These findings align with previous studies that have highlighted the importance of targeted interventions for specific postural imbalances in managing low back pain. For instance, Kim et al.[
The superior pain reduction in specific protocols may be attributed to the tailored approach addressing the specific muscle imbalances associated with each type of LCS. This targeted approach likely led to better neuromuscular balance and reduced stress on the lumbar spine, resulting in more effective pain relief. These results are consistent with the findings of Jeong et al.[
Similar to pain outcomes, all groups showed significant improvements in disability levels as measured by the Modified Oswestry Disability Questionnaire (MODQ). Again, the specific protocols demonstrated superior results, with group A1 achieving the highest median reduction in MODQ scores (45 points), followed by group A2 (28 points). These findings are consistent with previous research indicating that addressing specific postural imbalances can lead to improved functional outcomes in patients with low back pain.
For example, Paungmali et al.[
The greater improvement in disability scores for specific protocols may be due to the comprehensive approach targeting both muscle length and strength imbalances characteristic of each LCS type. By addressing these imbalances, patients likely experienced improved movement patterns and reduced compensatory strategies, leading to enhanced functional capacity.
The study also revealed significant changes in the lumbar lordosis index (LLI) across all groups. Notably, group A1 showed a substantial median decrease in LLI from 22.3 to 10.5, indicating a reduction in lumbar hyperlordosis. Conversely, group A2 demonstrated an increase in LLI from 6.3 to 13.6, suggesting an improvement in lumbar hypolordosis. These changes in LLI were more pronounced in the specific protocol groups compared to the generalized protocol groups.
These findings highlight the efficacy of specific exercises in modifying lumbar curvature, which is crucial in addressing the underlying postural imbalances associated with LCS. The targeted approach of stretching and strengthening exercises likely contributed to the restoration of a more neutral spinal alignment. This is in line with the work of Kim et al.[
The results revealed significant improvements in abdominal muscle strength across all groups, with specific protocols yielding superior outcomes. Group A2, which received the specific protocol for anterior LCS/lumbar hypolordosis, demonstrated the most substantial improvement in abdominal strength (median increase of 8 kg). These findings support the importance of core strengthening in the management of low back pain, as highlighted by Akuthota et al.[
The superior results observed in the specific protocols, particularly for anterior LCS, underscore the effectiveness of targeted interventions in addressing specific muscle weaknesses associated with different types of LCS. This aligns with the findings of Hlaing et al.[
The results showed significant improvements in both abdominal and gluteal muscle strength across all groups, with specific protocols demonstrating superior outcomes. Group A2 exhibited the most substantial improvements in abdominal strength (median increase of 8 kg) and gluteal muscle strength (median increase of 8 kg for both right and left sides). These findings are particularly noteworthy, as weak abdominal and gluteal muscles are key components of lower crossed syndrome.[
The significant improvements observed in the specific protocol groups suggest that these interventions effectively addressed the muscle imbalances characteristic of LCS. This is consistent with the work of Searle et al.[
The study demonstrated significant improvements in iliopsoas tightness across all groups, with specific protocols showing superior results. Group A1, which received the specific protocol for posterior LCS/lumbar hyperlordosis, exhibited the greatest median reduction in iliopsoas tightness (12 degrees for both right and left sides), followed by group A2 (2 degrees for both sides). These findings align with previous research by Malai et al.[
The more substantial improvements observed in the specific protocol groups, particularly group A1, suggest that tailored interventions are more effective in addressing the specific muscle imbalances associated with LCS. This is consistent with the work of Kim et al.[
Interestingly, the study revealed a significant reduction in back extensor tightness across all groups, with group A1 showing the most substantial median increase (6.5 degrees). This finding may seem counterintuitive at first, but it could be explained by the concept of adaptive shortening of the antagonist muscles as proposed by Janda et al.[
This phenomenon is supported by the work of Page et al.[
This study provides compelling evidence for the superiority of specific treatment protocols over generalized protocols in the management of low back pain associated with lower cross syndrome (LCS). The findings demonstrate that tailored interventions addressing the specific postural imbalances present in each type of LCS lead to significantly better outcomes across multiple parameters, including pain reduction, disability improvement, lumbar lordosis correction, muscle strength enhancement, and flexibility improvement.
The specific treatment protocols, particularly for posterior LCS/lumbar hyperlordosis (group A1) and anterior LCS/lumbar hypolordosis (group A2), consistently outperformed the generalized treatment protocols in all measured outcomes. This highlights the critical importance of accurate assessment and classification of LCS types in patients presenting with low back pain.
The superior outcomes achieved with specific protocols across all measured parameters (pain, disability, lumbar lordosis index, muscle strength, and muscle tightness) reinforce the importance of accurate assessment and classification of LCS types in patients with low back pain. This approach aligns with the concept of classification-based treatment for low back pain, which has shown promising results in previous studies.[
The findings suggest that clinicians should consider tailoring their treatment approaches based on the specific postural imbalances present in each patient with LCS. This individualized approach may lead to more effective management of low back pain associated with LCS and potentially faster recovery times. The results also highlight the potential limitations of generalized exercise protocols in addressing the specific needs of patients with different types of LCS.
Furthermore, the significant improvements in muscle strength and flexibility observed in the specific protocol groups emphasize the importance of targeted strengthening and stretching exercises in the management of LCS. This is consistent with the findings of Liebenson[
While the study provides valuable insights into the effectiveness of specific treatment protocols for LCS, some limitations should be considered. The relatively short intervention period of two weeks may not fully capture the long-term effects of these treatment protocols. Future studies should consider longer follow-up periods to assess the sustainability of the observed improvements and to monitor the potential normalization of back extensor tightness over time.
Additionally, investigating the potential influence of factors such as age, gender, and BMI on treatment outcomes could provide valuable insights for tailoring interventions to specific patient populations. Future research could also explore the combination of specific exercise protocols with other interventions, such as manual therapy or ergonomic modifications, to potentially enhance treatment outcomes further.
We would like to express our gratitude to all participants for their support and cooperation during the study. We wish to acknowledge with gratitude Dr. Krupa Mehta and Dr. Bhavesh Kanabarsir for their valuable time, for solving our queries, and for giving valuable advice through this voyage.
All authors declare no conflicts of interest related to this manuscript.
Ethical clearance was obtained from the institutional ethics committee (human), PDU Medical College, Rajkot, vide reference number PDUMCR/IEC/19/2022, and a clinical trial registry was done for the study vide reference number CTRI/2022/07/044487.
Written informed consent was obtained to participate in the study and use the data for research and educational purposes.
We hereby confirm that the manuscript has been read and approved by all the authors. Each author believes that the manuscript represents honest and accurate work.