Correlation between spinal curvature, back and abdominal muscle strength and physical activity in premenopausal women with low back pain

Arati Mahishale; Henna Hakim; Hrishikesh Shetti

doi:10.4103/ijptr.ijptr_6_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 3 | Issue : 2 | Page : 112-116

Correlation between spinal curvature, back and abdominal muscle strength and physical activity in premenopausal women with low back pain

Arati Mahishale, Henna Hakim, Hrishikesh Shetti
Department of Obstetrics and Gynecology Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission	15-Mar-2021
Date of Decision	22-Nov-2021
Date of Acceptance	18-Dec-2021
Date of Web Publication	12-Jan-2022

Correspondence Address:
Dr. Arati Mahishale
Department of Obstetrics and Gynecology Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_6_21

Abstract

Context: Premenopause is the time before the cessation of menstruation and onset of menopausal symptoms. Information regarding the degree of association of spinal curvature, back and abdominal muscles strength, and physical activity to low back pain (LBP) in premenopausal women is underreported which is useful for awareness, prevention, and optimal treatment.
Aims: The aim is to determine the correlation between spinal curvature, back and abdominal muscle strength, and physical activity in premenopausal women with LBP.
Materials and Methods: Eighty-four premenopausal women aged between 45 and 55 years were selected based on the inclusion criteria. Three physical characteristics: spinal curvature, back and abdominal muscle strength, and physical activity were measured for all the subjects, and the relative association of each characteristic with LBP was assessed. International Physical Activity Questionnaire (IPAQ) short form was administered to all the participants, flexicurve was used for spinal curve measurement, and manual muscle testing for abdominal and back extensor strength was recorded.
Statistical Analysis: Data were analyzed by descriptive statistics and correlated using Pearson's correlation.
Results: The mean kyphosis was 36.79° ± 6.41° and lordosis was 33° ± 7.75° According to MRC grading mean abdominal strength was 3.57 ± 0.68 (Grade 3: 53.6%; Grade 4: 35.7% and Grade 5: 10.7%) and back strength was 3.22 ± 0.52 (Grade 2: 4.8%; Grade 3: 67.9% and Grade 4: 27.4%). The mean IPAQ score observed was 1.94 ± 0.64 (low: 23.8%; moderate: 58.3% and high: 17.9%).
Conclusion: An inverse relationship was observed between age, IPAQ score, lumbar lordosis, and back and abdominal muscle strength, with increasing age in premenopausal women there was a decrease in physical activity, lumbar lordosis, and back and abdominal muscle strength.

Keywords: Kyphosis, Lordosis, Low back pain, Muscle strength, Physical activity, Premenopause, Spinal curvature

How to cite this article:
Mahishale A, Hakim H, Shetti H. Correlation between spinal curvature, back and abdominal muscle strength and physical activity in premenopausal women with low back pain. Indian J Phys Ther Res 2021;3:112-6

How to cite this URL:
Mahishale A, Hakim H, Shetti H. Correlation between spinal curvature, back and abdominal muscle strength and physical activity in premenopausal women with low back pain. Indian J Phys Ther Res [serial online] 2021 [cited 2023 Apr 1];3:112-6. Available from: https://www.ijptr.org/text.asp?2021/3/2/112/335670

Introduction

Premenopause refers to the time before which a female's body makes the natural transition to menopause. Menopause is the end of the menstrual cycle period in a woman and is diagnosed after a woman does not have a menstrual period for 12 months.^[1] As their life expectancy increases, modern women live a third of their life in menopause.^[2] According to Whelan et al., 80% of women suffer from many menopausal symptoms including musculoskeletal conditions.^[3] One such condition is chronic low back pain (LBP) which is one of the major health problems seen in premenopausal women. The prevalence of LBP was between 33.7% and 82.5% which is caused due to change in the muscle tension or stiffness.^[4] The Global Burden of Diseases study ranked LBP as the leading cause of disability of 291 conditions examined and sixth in terms of disability-adjusted life years increasing from 58.2 million in 1990 to 83 million in 2010.^[5] Furthermore, according to Janda, pain led to resultant tightening of trunk extensor and weakness of abdominal musculature. According to the World Health Organization, physical activity is defined as a behavior that involves human movement, resulting in the physiological attribute including increased energy expenditure and improved physical fitness reduced the risk of musculoskeletal disorder.^[6] The nature and intensity of physical activity as well as reduced physical activity or inactivity may lead to decreased muscle strength and reduced bone mineral density.^[7],[8] It has been observed that inactivity is the fourth most leading cause of global mortality. In premenopausal women due to LBP, reduced level of physical activity is observed.^[9] LBP may also lead to decreased levels of physical activity which mainly affects prolonged standing, forward bending to lift objects, squatting, and sitting without support for a prolonged time. Controversy exists regarding the degree of association between characteristics such as spinal curvature, back and abdominal muscle strength, and physical activity in premenopausal women with chronic mechanical LBP. Information regarding the degree of the association of each factor to LBP in premenopausal women is underreported which is useful for awareness, prevention, and optimal treatment.

Subjects and Methods

One hundred and thirteen participants between the age of 45–55 years were screened out of which 29 did not have LBP so were excluded. Eighty-four subjects were recruited and volunteered to take part in the study. The present research is a cross-sectional study where measurements of thoracic kyphosis, lumbar lordosis, abdominal, back muscles strength, and physical activity was taken. The sample size was open-ended and convenient sampling was done. All subjects were evaluated by the researcher according to the following criteria after obtaining consent. The inclusion criteria was premenopausal women premenopausal women between the age of 45 and 55 years, nonspecific diagnosed cases of chronic LBP, and working women, the exclusion criteria being individuals with spinal surgery or vertebral fracture, history of traumatic spinal cord injury/ Road Traffic Accident (RTA), surgical menopause, and systemic illness leading to LBP. Women were involved in usual activities of daily living according to their age range. Research and Ethics Committee approval was taken for this study. All data were collected in a span of 3 months.

Measurement of thoracic kyphosis and lumbar lordosis

The measurement of kyphotic angle was performed in accordance with the standard protocol using a flexicurve ruler having excellent intrarater (intraclass correlation coefficient [ICC] = 0.94) and interrater (ICC = 0.86) reliability.^[10] The thoracic kyphosis was evaluated with the subject standing barefoot and the weight being equally distributed on both feet in their usual posture. The subject was familiarized with the procedure, one practice was performed by taking the values by positioning the flexicurve along the spinal contour to procure the angle of spinal curvature, i.e., kyphosis and lordosis. The subject is positioned in standing and the examiner is standing behind the subject. The flexicurve is first put up at C7 vertebrae protuberance till S2 sacral vertebrae and shaped along the length of the spine once the flexicurve takes the form of the spinal contour it is put up on a graph paper.^[11] All subjects were evaluated by one examiner. Thoracic kyphosis and lumbar lordosis were then calculated using the formula: 4 arc tan 2 h/L. Where, h, i.e., height of the curvature which was the deepest point of the curve and L, i.e., length of the curve, was measured from C7 to T12 and from T12 to S2 for the thoracic and lumbar spine, respectively.

Measurement of muscle strength

The maximum dynamic strength of the back extensors and abdominal flexors was measured in supine and prone position as per the manual muscle testing protocols described by Daniel and Worthingham.^[12] The subject was asked to lie in supine for abdominal muscle strength testing and prone lying for back muscle strength testing accordingly with hands grasping behind the head and the therapist standing beside at the level of the chest to check the clearance of the scapula.

Assessment of physical activity

The level of physical activity was assessed through a self-administered International Physical Activity Questionnaire (IPAQ) short form given to each subject which included four domains: Work domain, active transportation domain, domestic and garden domain, and leisure-time domain. This questionnaire then categorizes the participants into three categories, namely, low, moderate, and high physical activity scores.

Statistical analysis

The statistical analysis of the collected data was done using the SPSS software 21 version. The statistical measures used were mean, standard deviation, and Pearson's correlation.

Results

For interpretation of the result, the data recorded were analyzed using descriptive statistics, and the IPAQ score was then correlated by Pearson correlation analysis as shown in [Table 1] and [Figure 1]. The mean age of the participants was 49.90 ± 3.16. Among 84 women, who participated in the study, the mean IPAQ score observed was 1.94 ± 0.64. Majority of the women, i.e. 58.3% performed a moderate level of physical activity followed by low physical activity reported by 23.8% of women and the least being 17.9% of women reported having high physical activity as shown in [Figure 2]. On correlating the age with other physical characteristics using Pearson correlation, a positive correlation was found between age and the other physical attributes as shown in [Table 2]. On further analysis, it was seen that among the 84 premenopausal subjects, the mean abdominal musculature strength as per the Medical Research Council (MRC) grading was 3.57 ± 0.68 with 53.6% of women having low abdominal muscle strength followed by moderate strength seen in 35.7% of women and only 10.7% of women having Grade 5 muscle strength while the mean back musculature strength among these women was 3.22 ± 0.52. On testing the back musculature, it was observed that the majority of women, i.e., 67.9% had Grade 3 muscle strength followed by only 27.4% having Grade 4 back muscle strength and 4.8% with Grade 2 back muscle strength as shown in [Figure 3]. The study also determines that with the increasing age of the subject, the angle of kyphosis increases and the lordosis decreases. While the relationship between the IPAQ score and thoracic curvature is inverse in nature, i.e., with a high IPAQ score, the kyphotic angle observed was low mean angle being 36.79° ± 6.41° whereas the lordosis was observed having a direct relationship, i.e., with a high IPAQ score there is an increase in lordotic curvature mean angle being 33° ± 7.75° seen in the subject.

Table 1: Descriptive analysis of the physical characteristics among premenopausal women

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Table 2: The correlation association was studied for age and physical characteristics among premenopausal women

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Figure 1: Graphical representation of descriptive analysis of physical characteristics in premenopausal women

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Figure 2: Graphical representation of International Physical Activity Questionnaire score among premenopausal women with low back pain

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Figure 3: Graphical representation of abdominal and back musculature strength frequency

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Discussion

In the present study done on 84 premenopausal, we found that there was a significant increase in thoracic kyphosis and decrease in lumbar lordosis due to LBP. When compared with physical activity, the IPAQ score showed a moderate score in the majority of premenopausal women with chronic mechanical LBP (23.8% low; 58.3% moderate; 17.9% high physical activity). A study done by Cutler et al. in year 1993 showed that the prevalence of kyphosis in healthy pre- and post-menopausal women was 35%. He also reported 29% of women had LBP by the age of 55 years.^[11] The present study also noted an increase in kyphosis as measured by flexicurve which is in consensus with the above study that with an increase in age in premenopausal women, there is an increase in thoracic kyphosis leading to secondary changes in lumbar lordosis. Relationship between mechanical factor and incidence of LBP done by Nourbakhsh and Arab in the year 2002 said that weakness and endurance of muscle are associated with LBP and other structural factors such as lumbar lordosis, pelvic tilt, lower limb discrepancy and length of abdominal, iliopsoas, and hamstring muscle are not associated with LBP.^[13] The present study also showed that women with chronic LBP had low abdominal and back muscle strength, i.e., 53.6% had Grade 3 abdominal strength and 67.9% of women had Grade 3 and 4.8% had Grade 2 back muscle strength. Lumbar lordosis in acute and chronic LBP patients a study was done by Evcik and Yücel et al. in 2003 had 50 patients with chronic LBP and acute LBP each concluded that chronic LBP affects the lower lumbar spine and limits the maximal range of lumbar extension.^[14] In the current study, we concluded that with aging the kyphotic angle increases and the lordosis reduces in the participants. Study by Teichtahl et al. physical inactivity is associated with narrower lumbar intervertebral discs, high-fat content of paraspinal muscles, and LBP and disability in 2015 concluded that physical inactivity is associated with high intensity LBP.^[5] The current study showed that women complaining of LBP had reduced physical activity due current lifestyle with an IPAQ score being 23.8% low, 58.3% moderate, 17.9% high which means that women have been affected with their physical activity due to LBP. Level of Physical Activity and Attitude toward Physical Activity in Perimenopausal Women in India a study done by Dr. Parle and Dhobale in 2018 concluded that women aged between 45 and 55 years majorly had a moderate level of physical activity and also observed that higher physical activity leads to lesser premenopausal symptoms.^[15] The present study also observed the majority of women having a moderate IPAQ score, i.e., 58.3%.

Conclusion

The present study showed that in premenopausal women with chronic mechanical LBP aged 45–55 years with increasing age there exists a positive correlation between age and the other physical attributes. The study also determines that with the increasing age of the subject, the angle of thoracic kyphosis increased and lumbar lordosis decreased. While the relationship between the physical activity and thoracic curvature is inverse in nature. Whereas the lumbar lordosis was observed having a direct relationship, i.e., with increase in age in premenopausal women, there was a decrease in physical activity, lumbar lordosis, and back and abdominal muscle strength.

Acknowledgment

We would like to thank our Principal for allowing us to conduct our study in the Institutional premises. We would also like to specially acknowledge the participants for their valuable time and cooperation given for the study without whom this study would not have been possible. Special thanks to our research guide for her guidance, valuable inputs, and suggestions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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