Effects of sleep hygiene and breathing exercises on pain, disability, and sleep in patients with chronic low back pain

Öz

Purpose: This study aims to investigate the effects of adding sleep hygiene education and breathing exercises to core stabilization exercises on pain, disability, and sleep parameters in patients with chronic low back pain (CLBP). Methods: Individuals diagnosed with CLBP were randomly assigned to three groups. The first group, received only TENS and superficial heat, forming the classical physiotherapy group (CPT). The second group received TENS and superficial heat combined with stabilization exercises, forming the lumbar stabilization exercise group (LSE). The third group received TENS, superficial heat, lumbar stabilization exercises, breathing exercises, and sleep hygiene education, forming the sleep hygiene and breathing exercise group (SHBE). All groups underwent a 3-week face-to-face treatment phase initially. Subsequently, the LSE and SHBE groups continued with a 5-week home exercise program. Pain intensity was assessed using the Visual Analogue Scale and the short form of the McGill Pain Questionnaire; disability with the Oswestry Disability Index; sleep quality with the Pittsburgh Sleep Quality Index, and daytime sleepiness with the Epworth Sleepiness Scale. Assessments were conducted at baseline, at 3 weeks (post-treatment), and at 8 weeks (follow-up). Results: Compared to baseline, significant differences were observed between groups at post-treatment and follow-up periods. The LSE and SHBE groups were more effective than the CPT group in reducing pain intensity, decreasing disability levels, improving sleep quality, and reducing daytime sleepiness (p<0.05). However, no significant differences were found between the LSE and SHRE groups for these parameters (p>0.05). Conclusion: This study demonstrates that the LSE and SHBE groups were more effective than the CPT group in improving pain, disability, and sleep parameters. However, the addition of sleep hygiene education and breathing exercises did not provide additional benefits compared to core stabilization exercises alone in patients with CLBP. More comprehensive studies are needed to evaluate long-term effects.

Anahtar Kelimeler

• Low back pain
• Core stabilization
• Sleep hygiene
• Breathing exercises
• Sleep.

Kronik bel ağrılı hastalarda uyku hijyeni ve solunum egzersizlerinin ağrı, özürlülük ve uykuya etkisi

Öz

Amaç: Kronik bel ağrısı (KBA) olan hastalarda kor stabilizasyon egzersizlerine eklenen uyku hijyeni eğitimi ve solunum egzersizlerinin ağrı, özürlülük, uyku parametreleri üzerindeki etkilerini araştırmayı amaçlamaktadır. Yöntem: KBA tanısı konan bireyler, randomize olarak üç gruba ayrıldı. Birinci grup yalnızca TENS ve yüzeyel ısı uygulanan klasik fizyoterapi grubu (KFT), ikinci grup TENS, yüzeyel ısı ve kor stabilizasyon egzersizlerini içeren lumbar stabilizasyon egzersizi grubu (LSE) ve üçüncü grup TENS, yüzeyel ısı, kor lumbar stabilizasyon egzersizleri, solunum egzersizleri ve uyku hijyeni eğitimi uygulanan uyku hijyeni ve solunum egzersizleri grubudur (UHSE). Tüm gruplar, ilk aşamada 3 haftalık yüzyüze tedavi aldı. Daha sonra LSE ve UHSE grupları ilave olarak 5 hafta boyunca ev programlarına devam ettiler. Ağrı şiddeti Vizüel Ağrı Skalası ve McGill Ağrı Kısa Formu, özürlülük Oswestry Özürlülük İndeksi, uyku kalitesi Pittsburgh Uyku Kalite İndeksi ve gündüz uykululuğu Epworth Uykululuk Ölçeği ile değerlendirildi. Değerlendirmeler tedavi başlangıcında, 3. haftada (tedavi sonrası) ve 8. haftada (takip dönemi) yapıldı. Bulgular: Başlangıç değerlerine kıyasla, tedavi sonrası ve takip döneminde gruplar arasında anlamlı farklar saptandı. LSE ve UHSE grupları, KFT grubuna göre ağrı şiddetini azaltma, özürlülük düzeyini düşürme, uyku kalitesini artırma ve gündüz uykululuğunu azaltmada daha etkili bulundu (p<0.05). Ancak, LSE ve UHSE grupları arasında bu parametrelerde anlamlı bir fark tespit edilmedi (p>0.05). Sonuç: Bu çalışma, LSE ve UHSE gruplarının, KFT grubuna kıyasla ağrı, özürlülük ve uyku parametrelerini iyileştirmede daha etkili olduğunu gösterdi. Uyku hijyeni eğitimi ve solunum egzersizlerinin eklenmesi, yalnızca kor stabilizasyon egzersizlerine kıyasla KBA hastalarında ek bir fayda sağlamadı. Uzun vadeli etkileri değerlendirmek için daha kapsamlı çalışmalara ihtiyaç vardır.

Anahtar Kelimeler

• Bel ağrısı
• Kor stabilizasyon
• Uyku hijyeni
• Solunum egzersizleri
• Uyku.

Kaynakça

1. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017; 389:736-47.
2. Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012; 64:2028-2037.
3. DePalma MG. Red flags of low back pain. JAAPA. 2020; 33:8-11.
4. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J. 2008; 8:8-20.
5. Charokopos A, Card ME, Gunderson C, et al. The Association of Obstructive Sleep Apnea and Pain Outcomes in Adults: A Systematic Review. Pain Med. 2018;19(suppl_1): S69-S75. Jones JD, Mogali S, Comer SD. Polydrug abuse: a review of opioid and benzodiazepine combination use. Drug Alcohol Depend. 2012; 125:8-18.
6. Krismer M, van Tulder M. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific). Best Pract Res Clin Rheumatol. 2007; 21:77-91.
7. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017; 166:514-530.
8. Björck-van Dijken C, Fjellman-Wiklund A, Hildingsson C. Low back pain, lifestyle factors and physical activity: a population based-study. J Rehabil Med. 2008; 40:864-869.

9. Agnus Tom A, Rajkumar E, John R, et al. Determinants of quality of life in individuals with chronic low back pain: a systematic review. Health Psychol Behav Med. 2022; 10:124-144.
10. Alsaadi SM, McAuley JH, Hush JM, Maher CG. Prevalence of sleep disturbance in patients with low back pain [published correction appears in Eur Spine J. 2012;21:554-560.
11. Gorji SM, Mohammadi Nia Samakosh H, Watt P, et al. Pain Neuroscience Education and Motor Control Exercises versus Core Stability Exercises on Pain, Disability, and Balance in Women with Chronic Low Back Pain. Int J Environ Res Public Health. 2022;19:2694.
12. Kang JI, Jeong DK, Choi H. Effect of exhalation exercise on trunk muscle activity and oswestry disability index of patients with chronic low back pain. J Phys Ther Sci. 2016;28:1738-1742.
13. Zambelli Z, Halstead EJ, Fidalgo AR, Dimitriou D. Good sleep quality improves the relationship between pain and depression among individuals with chronic pain. Front Psychol. 2021; 12:668930.
14. Atilgan ED, Tuncer A. The effects of breathing exercises in mothers of children with special health care needs: A randomized controlled trial. J Back Musculoskelet Rehabil. 2021;34:795-804.
15. Campanini MZ, González AD, Andrade SM, et al. Bidirectional associations between chronic low back pain and sleep quality: a cohort study with schoolteachers. Physiol Behav. 2022; 254:113880.
16. Mammadov T, Şenlikci HB, Ayaş Ş. A public health concern: Chronic low back pain and the relationship between pain, quality of life, depression, anxiety, and sleep quality. J Surg Med. 2020;4:808-811.
17. Taheri Tanjani P, Khodabakhshi H, Etemad K, et al. Effect of sleep hygiene education on sleep quality and general health of elderly women with sleep disorders living in Birjand City, Iran, in 2016. Iran J Ageing. 2019;14:248-259.
18. Shamsi MB, Sarrafzadeh J, Jamshidi A. Comparing core stability and traditional trunk exercise on chronic low back pain patients using three functional lumbopelvic stability tests. Physiother Theory Pract. 2015;31:89–98.
19. Faul F, Erdfelder E, Buchner A, et al. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2009;41:1149-1160.
20. Heller GZ, Manuguerra M, Chow R. How to analyze the Visual Analogue Scale: Myths, truths and clinical relevance. Scand J Pain. 2016;13:67-75.
21. Yakut Y, Yakut E, Bayar K, Uygur F. Reliability and validity of the Turkish version short-form McGill pain questionnaire in patients with rheumatoid arthritis. Clin Rheumatol. 2007;26:1083-1087.
22. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976). 2000;25:2940-2952.
23. Yakut E, Düger T, Oksüz C, et al. Validation of the Turkish version of the Oswestry Disability Index for patients with low back pain. Spine (Phila Pa 1976). 2004;29:581-585.
24. Buysse DJ, Reynolds CF, Monk TH, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193-213.
25. Ağargün, MY, Kara H, Anlar O. Pittsburgh Uyku Kalitesi İndeksi’nin Geçerliği ve Güvenirliği. Türk Psikiyatri Derg. 1996;7:107-111.
26. Izci B, Ardic S, Firat H, et al. Reliability and validity studies of the Turkish version of the Epworth Sleepiness Scale. Sleep Breath. 2008; 12:161-168.
27. Sluka KA, Bjordal JM, Marchand S, Rakel BA. What makes transcutaneous electrical nerve stimulation work? Making sense of the mixed results in the clinical literature. Phys Ther. 2013;93:1397-1402.
28. Haynes W. Rolling exercises designed to train the deep spinal muscles. J Body Mov Ther. 2003;7:153-164.
29. García-Jaén M, Cortell-Tormo JM, Hernández-Sánchez S, et al. Influence of Abdominal Hollowing Maneuver on the Core Musculature Activation during the Prone Plank Exercise. Int J Environ Res Public Health. 2020;17:7410
30. Lillehei AS, Halcón LL, Savik K, et al. Effect of Inhaled Lavender and Sleep Hygiene on Self-Reported Sleep Issues: A Randomized Controlled Trial. J Altern Complement Med. 2015;21:430-438.
31. Gupta CC, Sprajcer M, Johnston-Devin C, et al. Sleep hygiene strategies for individuals with chronic pain: a scoping review. BMJ Open. 2023;13:e060401.
32. Mendes LP, Moraes KS, Hoffman M, et al. Effects of Diaphragmatic Breathing With and Without Pursed-Lips Breathing in Subjects With COPD. Respir Care. 2019;64:136-144.
33. Anderson BE, Bliven KCH. The Use of Breathing Exercises in the Treatment of Chronic, Nonspecific Low Back Pain. J Sport Rehabil. 2017;26:452-458.
34. Maher JM, Markey JC, Ebert-May D. The other half of the story: effect size analysis in quantitative research. CBE Life Sci Educ. 2013;12:345-451.
35. Rajfur J, Pasternok M, Rajfur K, et al. Efficacy of Selected Electrical Therapies on Chronic Low Back Pain: A Comparative Clinical Pilot Study. Med Sci Monit. 2017;23:85-100.
36. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018; 391:2356-2367.
37. Kim B, Yim J. Core Stability and Hip Exercises Improve Physical Function and Activity in Patients with Non-Specific Low Back Pain: A Randomized Controlled Trial. Tohoku J Exp Med. 2020;251:193-206.
38. França FR, Burke TN, Hanada ES, et al. Segmental stabilization and muscular strengthening in chronic low back pain: a comparative study. Clinics (Sao Paulo). 2010; 65:1013-1017.
39. Kaila-Kangas L, Kivimäki M, Härmä M, et al. Sleep disturbances as predictors of hospitalization for back disorders-a 28-year follow-up of industrial employees. Spine (Phila Pa 1976). 2006;31:51-56.
40. Nijs J, Mairesse O, Neu D, et al. Sleep Disturbances in Chronic Pain: Neurobiology, Assessment, and Treatment in Physical Therapist Practice. Phys Ther. 2018;98:325-335.
41. Curatolo M, Müller M, Ashraf A, et al. Pain hypersensitivity and spinal nociceptive hypersensitivity in chronic pain: prevalence and associated factors. Pain. 2015;156:2373-2382.
42. Yabe Y, Hagiwara Y, Sekiguchi T, et al. Association Between Sleep Disturbance and Low Back Pain: A 3-Year Longitudinal Study After the Great East Japan Earthquake. Spine. 2022;47:361-368.
43. Akodu AK, Akindutire OM. The effect of stabilization exercise on pain-related disability, sleep disturbance, and psychological status of patients with non-specific chronic low back pain. Korean J Pain. 2018;31:199-205.
44. Tuncer A, Kastal E, Tuncer AH, et al. The effect of sleep hygiene and physiotherapy on bruxism, sleep, and oral habits in children with sleep bruxism during the COVID-19 pandemic. J Back Musculoskelet Rehabil. 2023;36:1047-1059.