LBP Masuk 4

NEUROQUANTOLOGY | NOVEMBER 2022 | VOLUME 20 | ISSUE 15 | PAGE 1712-1721| DOI: 10.14704/NQ.2022.20.15.
NQ88156
Arif Pristianto et al / The Effectiveness of Aquatic Exerciseson Functional AbilityIn Patients With Chronic Low Back Pain
The Effectiveness of Aquatic Exerciseson

Functional AbilityIn Patients With Chronic
Low Back Pain
Arif Pristianto1*, Taufik Eko Susilo2, Farid Rahman3, Adnan Faris Naufal4, Wijianto5, SuryoSaputra
Perdana6, Muhammad Angga Al Athfal7, Yasyfi Addiningsih8, Peemongkon Wattananon9
CorespondenAuthor :arif.pristianto@ums.ac.id
1,2,3,4,5,6,7,8
Physiotherapy Department, Faculty of Health Science, Universitas Muhammadiyah
Surakarta, Jawa Tengah, Indonesia
9
Faculty of Physical Therapy, Mahidol University, Nakhon Pathom, Thailand
Abstract
Background and purpose:Chronic Low Back Pain (CLBP) is muscle pain or spasm in the lower back
area that is suffered for more than 12 weeks. CLBP results in inhibited body activity and decreased
functional ability. The spine is a supporting structure of the body and head that will be involved in 1712
various movements. The improper position of the body will lead to adisturbed spine or lower back,
which in turn results in a decreased quality of life. In industrialized countries, the prevalence of a
person experiencing low back pain reached 70% between the ages of 35-55 years. The purpose of
this study is to determine the effectiveness of the Aquatic Exercise program for improving the
functional abilities of Chronic Low Back Pain patients.
Methods:This type of research was a Quasi-Experimental Design using One Group Pre-Test - Post-
Test research design. The samples consisted of elevenpersons. They were given the treatment using
Aquatic Exercise. This study implemented the Oswestry Disability Index as the functional ability
measurement.
Results and discussion:Test results using the Paired Sample t-Test showed the value of p = 0.00 or p
<0.05. 4-week aquatic exercise program has an effect on functional ability in patients with CLBP.
Especially decreasing in Oswestry Disability Index (ODI) score.
Keywords: chronic low back pain, functional ability, aquatic exercise, Oswestry disability index.
DOI Number: 10.14704/NQ.2022.20.15.NQ88156 NeuroQuantology2022;20(15): 1712-1721

Introduction spontaneously recovered, some of patients
Low back pain is one of the most who have persisting low back
common musculoskeletal disorders in several symptomswouldtransform into chronic low
countries across the world(Meucci et al., back pain (CLBP)(Harries et al., 2016;
2015). Although low back pain can be Sanzarello et al., 2016)CLBP is defined as an
eISSN1303-5150 www.neuroquantology.com
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NEUROQUANTOLOGY | NOVEMBER 2022 | VOLUME 20 | ISSUE 15 | PAGE 1712-1721| DOI: 10.14704/NQ.2022.20.15.NQ88156
ache that occurs between the lower back or incorporate properties of the water
ribs and gluteal folds that last more than 12 (buoyancy, hydrostatic
weeks (Patrick et al., 2016). pressure,hydrodynamic forces,
CLBP can be caused by a variety of thermodynamic, and viscosity) and
sources ranging from injury, disease, or stress movementsto design appropriate exercise
to various structures (bones, muscles, program for patients with CLBP(Olson et al.,
ligaments, joints, nerves, or the spinal 2013). Aquatic exercises include several types
cord)(Goubert et al., 2017). More than 70% of of movements incorporating with the
people in industrialized countries experienced application of water properties to facilitate or
low back pain throughout their lives up to the resist the movements. Therefore, aquatic
age of 35-55 years (Mohammedali et al., exercises can increase muscle length and/or
2014). According to Meucci et al. (2015),they strength. The water property that facilitates
have reported that the prevalence of CLBP is the movement can help in stretching
4.2% at the age between 24-39 years and lumbopelvic muscles to improve muscle
19.6% at the age between 20-59 years. length (Pristiantoet al., 2018), while the
Prolonged static postures and/or property that resists the movement can be
repeated abnormal movements in daily useful to strengthen the lumbopelvic muscles
activities can cause excessive loading and/or (Yu & Park, 2013; Yuniarwati, 2019). Improved
shear forces on the lumbopelvic structures muscle length and strength could further
contributing to the occurrence of low back restore their normal functions which in turn
symptoms(Susanti, 2015).Several studies reducing the stress on the lumbopelvic
demonstrated lumbopelvic muscle weakness structures.However, there was limited 1713
and tightness (Park et al., 2016). These evidence to support the effect of aquatic
muscular impairments can compromise the exercises on functional ability in patients with
lumbopelvic stability during activities of daily CLBP
livings(Coulombe et al., 2017). In addition, Therefore, this study was to
one study has showed trunk postural control determine the effect of 4-week aquatic
deficits in patients with CLBP(Willigenburg et exercise program on functional ability in
al., 2012). Although several land-based patients with CLBP. We hypothesized that
exercise programs demonstrated the patients with CLBP would demonstrate
effectiveness in reducing pain and improving improvement in functional ability after 4-
functional ability, those exercises might not week aquatic exercise program. The findings
be suitable for some patients with CLBP, from this study would provide evidence to
particularly those with advanced age and/or support the usefulness of aquatic exercises as
overweight. Thissuggests the need for an alternative exercise program for patients with
alternate exercise program. CLBP.
Aquatic exercises have been
proposedan alternative form of exercises. The Methods
aquatic exercise program is defined as a Study design
therapeutic exercise program in the This study used a quasi-experimental
swimming pool that takesadvantage of water design to determine the effect of aquatic
properties designed by qualified clinicians to exercise on functional ability in patients with
reduce pain and increase physical CLBP.
functions(Olson et al., 2013). Clinicians can Subjects
2
Sample of convenience was used in Procedure

this study. Eleven patients with CLBP were The study protocol followed the
recruited from dr. SoedjonoHospital, principles of the Declaration of Helsinki and
MagelangIndonesia between December 2019 was approved by dr. SoedjonoHospital (COA
and January 2020. Inclusion criteria were protocol number:34/EC/XII/2019). Patients
adults who has back pain problem, adult provided a written informed consent prior to
categories, and able to participate with the participating in this study. Potential patients
programs. Patients were excluded if they have were screened based on inclusion and
pain score by Visual Analogue Scale (VAS) > 7 exclusion criteria. Eligible patients were asked
points, injury in spinal and lower extremity < 6 to rate their functional ability using the ODI.
months, and aquaphobia. Then, patients received 4-week aquatic
Instrument and measure exercise program. After completion of the
Oswestry Disability Index (ODI) was exercise program, the patients were asked to
used to measure patients’ functional ability in rate their functional ability again. Pre- and
daily activitiesNishant et al. (2014)Lee et al. post-intervention scores were further used
(2017). The ODI has been previously validated for data analysis.
and its reliability has been established(Yates Intervention
& Shastri-hurst, 2017). It is composed of 10 Aquatic exercises include several
questions. Each question is scored between 0 types of movements incorporating with the
and 5 (0 represents on disability and 5 application of water properties to facilitate or
represents most severe disability). The total resist the movements. Therefore, aquatic
score is converted to percentage (0-100%; exercises can increase muscle length and/or
0%-20% =minimal disability, 21%-40% = strength. The water property that facilitates
moderate disability, 41%-60% = severe the movement can help in stretching
1714
disability, 61%-80% = crippling back pain, and lumbopelvic musclesto improve muscle length
81%-100% = bed-bound or having (Pristiantoet al., 2018), while the property
exaggeration of the symptoms).Minimal that resists the movement can be useful to
detectable change of 12.72% has been strengthen the lumbopelvic muscles(Yu &
reported. The percentage change greater than Park, 2013).Improved muscle length and
12.88% is consider as minimally clinically strength could further restore their normal
important change. The ODI was used to functions which in turn reducing the stress on
measure functional ability before and after 4- the lumbopelvic structures.
week aquatic exercise. These data were used
to determine the effect of aquatic exercise on
functional ability in patients with CLBP.
3
Figure 1: Cervical Spine: Lateral Flexion
1715
Figure 2: Pelvic Tilt
Figure 3: Hamstring Stretching
Statistical analysis
4
All statistical analyses were Results

performed using SPSS program version 21 Patient characteristic data (Table 1)
(IBM Corp., NY, USA). Descriptive statistics demonstrated mean age was 53  9.6years,
including mean, standard deviation, 72.7% were female, and mean BMI was XX
frequency, and percentage were used to kg/m2 (81.8% overweight and obese).
describe patients’ characteristics. Shapiro- 81.8% of patients were not currently
Wilk test was used to determine normality working (7 housewives and 2 retired). A
of the ODI score.We found the ODI data dependent t-test demonstrated significant
were normally distributed; therefore, a improvement in ODI(p<0.001) between pre
dependent t-test was used to determine (47.45  4.01) and post (20.36  3.67)with
the effect of 4-week aquatic exercise on the reducing ODI score was greater than
functional ability in patients with CLBP. MCID (27.09>12.88) 4-week aquatic
Significant level was held at 0.05. exercise program.
Table 1.Patient characteristics

Parameter Value
Mean ageSD (years) 539.6
Gender (male/female) 3/8
Mean BMISD (kg/m2) 26.43.16
SD = standard deviation, BMI = body mass index 1716
Discussion forces perpendicular to the body surface,

This study aimed to determine the particularly at the joint surface, resulting in
effect of 4-week aquatic exercise program increased joint position sense(Ariyoshi et
on functional ability in patients with CLBP. al., 1999; Dundar et al., 2009). Hydrostatic
Our result supports the hypothesis in which pressure on the body surface can also
patients with CLBP would demonstrate trigger gate control theory leading to pain
improvement in functional ability after 4- reduction and improvement in physical
week aquatic exercises. Reduction in ODI functions(Hossein Abadi et al., 2018).
scores suggests the effectiveness of aquatic According to hydrodynamic property, slow
exercise program to improve the ability of movement can cause laminar flow
patients with CLBP to perform activities of facilitating the movement, while fast
daily livings. movement cause turbulent flow resisting
Water has many unique properties the movement(Noh et al., 2008). For
that make it a preferred therapeutic thermodynamic, lower temperature water
exercise program overthe other is preferable for high intensity exercise
therapeuticexercise programs.Buoyancy because heat can be transferred easily in
can reduce the gravitational forces causing the water, whereas high temperature
stress on the lumbar spine. It also helpsto water is suitable for exercises to improve
facilitate the movement during mobility and flexibility(Shi et al., 2018).
exercises(Gordon & Bloxham, 2016; Louw Viscosity of water can be used as a
et al., 2016; Waller et al., 2009). resistance during aquatic exercises to
Hydrostatic pressure providescompression
improve muscle strength(Hossein Abadi et CLBPwas higher in women agedgreater

al., 2018). than 60 years (Umboh et al., 2017).
Our finding is consistent with other Therefore, our findings should be able to
aquatic exercise studies. One systematic generalize to the CLBP population.
review with meta-analysis of aquatic Overweight and obese persons can
exercises in patients with low back pain increase the load on the lumbopelvic region
demonstrated aquatic exercises can reduce resulting in increased risksof lumbopelvic
pain and improve physical functions (Shi et injury (Hadyan & Saftarina, 2015). An
al., 2018). These findings suggest the increase in BMI would mandate
effectiveness of aquatic exercises for lumbopelvic muscles to generate greater
patients with low back pain. Han et al. forces to stabilize the lumbopelvic area
(2011) demonstrated aquatic exercises can during static postures and movements.
increase the strength of the lower back Increase in BMI can cause a blockage in
muscles and reduce pain in elderly women blood flow to the lumbopelvic region which
with low back pain (Konlian, 1999). Another could compromise the healing process
evidence from study by Pabian & Kolber resulting in incomplete recovery and
(2018) supports that aquatic exercise prolonged chronicity of low back
program is effective for patients with low pain(Tanderi et al., 2017). Our results
back pain to improve the ability to perform demonstrated that most patients with CLBP
activities of daily livings (Konlian, 1999) In were housewives who tended to be less
addition, Barker et al. (2014) reported that active than currently working women. Less
aquatic exercises have beneficial effects on active would be likely to have muscle
pain, physical function, and quality of life weakness and joint stiffness which could be
for adults with musculoskeletal complaints the risks of low back pain and limitations in
(Pabian & Kolber, 2018). their activities(Rinaldi et al., 2015). This
Patient characteristics indicate that could explain the positive response to the
the majority of patients with CLBP in our aquatic exercises in our study. 1717
study were elderly females.Physiologically, The findings of this study should be
women have lesser muscle capacity than considered in light of the following
men (Ref). The menopause process in limitations. This study investigated in small
women can cause reduction in bone sample size and single clinical outcome
density due toa decrease in estrogen measure. Therefore, there is a need for a
production (AZ et al., 2019), while aging study with larger sample size and utilizing
can cause decrease in bone several clinical measurements(e.g.,pain,
elasticity(Purnamasari et al., 2010). muscle strength, balance,etc.) to represent
Therefore, thiswouldincrease the rate of various clinical features. Lack of control
joint degeneration in elderly women which group would limit the interpretation of
in turn increasing the stress on the aquatic exercises as it was difficult to
lumbopelvic structures causing low back isolate its effect from the course of natural
symptoms. In addition, Patrianingrum et al. recovery. Future study should include
(2015) found that gender and age were control group or comparative intervention
potential risk factors for low back pain. Our to better understanding the effect of
patient characteristics were similar to aquatic exercise program. We intended to
previous study reporting the risk of having increase the generalizability of the study;
thus, we did not control the intake of any Dengan Keluhan Nyeri Low Back Pain. REAL
medication as patients with low back pain in Nursing Journal (RNJ), 2(2).
commonly take medication for reducing Barker, A. L., Talevski, J., Sci, Bh., Morello,
their symptoms. In addition, adding aquatic R. T., Brand, C. A., Rahmann, A. E., &
exercises to medication could cause co- Urquhart, D. M. (2014). Effectiveness of
intervention effects. Therefore, future Aquatic Exercise for Musculoskeletal
study with medication restriction could Conditions : A Meta- Effectiveness of
isolate the actual effects of aquatic Aquatic Exercise for Musculoskeletal
exercises. Conditions : A Meta-Analysis. Archives of
Physical Medicine and Rehabilitation, 4(5).
Conclusion https://doi.org/10.1016/j.apmr.2014.04.00
This study aimed to determine the 5
effect of aquatic exercises on functional Coulombe, B. J., Games, K. E., Neil, E. R., &
ability in patients with CLBP. We found Eberman, L. E. (2017). Core stability
positive effect of aquatic exercises evident exercise versus general exercise for chronic
by increase in functional ability after 4- low back pain. Journal of Athletic Training,
week aquatic exercise program. Our 52(1), 71–72.
findings suggest the clinical usefulness of https://doi.org/10.4085/1062-6050-
aquatic exercise program for treating 51.11.16
patients with CLBP. However, replication of Dundar, U., Solak, O., Yigit, I., Evcik, D., & 1718
our study with larger sample size and Kavuncu, V. (2009). Clinical effectiveness of
control group is required. aquatic exercise to treat chronic low back
pain: a randomized controlled trial. Spine,
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NEUROQUANTOLOGY | NOVEMBER 2022 | VOLUME 20 | ISSUE 15 | PAGE 1712-1721| DOI: 10.14704/NQ.2022.20.15.

The Effectiveness of Aquatic Exerciseson

DOI Number: 10.14704/NQ.2022.20.15.NQ88156 NeuroQuantology2022;20(15): 1712-1721

Sample of convenience was used in Procedure

Figure 1: Cervical Spine: Lateral Flexion

Figure 2: Pelvic Tilt

Figure 3: Hamstring Stretching

All statistical analyses were Results

Table 1.Patient characteristics

Discussion forces perpendicular to the body surface,

improve muscle strength(Hossein Abadi et CLBPwas higher in women agedgreater

3 Medicine & Rehabilitation, 97(2), 116–122.

Rehabilitation, 9(3), 362–367. THERAPY TERHADAP PENINGKATAN

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