Clinical Biomechanics 73 (2020) 17–27

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Clinical Biomechanics
journal homepage: www.elsevier.com/locate/clinbiomech

Effect of different exercise programs on non-specific chronic low back pain T

and disability in people who perform sedentary work
⁎
Saule Sipavicienea, , Irina Klizieneb
a
Department of Applied Biology and Rehabilitation, Lithuanian Sports University, Lithuania
b
Department of Education Science, Kaunas University of Technology, Lithuania

A R T I C LE I N FO A B S T R A C T

Keywords: Background: This study compared the short- and long-term effects of different exercise programs on lumbar
Exercises muscle function, cross-sectional area of the multifidus muscle, functional disability and low back pain in people
Low back pain who perform sedentary work.
Multifidus muscle Methods: A total of 70 volunteer women with sedentary occupations suffering from low back pain were ran-
Strength
domized to either the lumbar stabilization exercise program group or the lumbar muscle strengthening exercise
program group. All subjects entered the 20-week exercise programs. The measurement of the cross-sectional area
of the multifidus muscle was executed by using an ultrasound system, isokinetic peak torque was measured
applying an isokinetic dynamometer.
Findings: The results indicated that the 20-week exercise programs reduced low back pain and functional dis-
ability. Positive effects for the cross-sectional area of the multifidus muscle, functional disability and low back
pain lasted for 4 weeks after the application of lumbar muscle strengthening exercise program and for 12 weeks
after the application of lumbar stabilization exercise program. The lumbar muscle strength increased and lasted
for 8 weeks after both exercise programs.
Interpretation: The 20-week lumbar stabilization exercise and muscle strengthening exercise programs were
efficacious in decreasing LBP and functional disability in people performing sedentary work, however the
lumbar stabilization exercise program was more effective, and this effect lasted for 12 weeks after completion of
the program.

1. Introduction weakened posterior lumbar structures (Corlett, 2006; Kingma et al.,

2000). One of the risk factors of LBP is weakness of the superficial and
Non-specific chronic low back pain (LBP) is a rather common and deep trunk and abdominal muscles, therefore strengthening these
predominant health problem worldwide that affects people of all ages muscles significantly reduces functional disability and pain (Danneels
(Maher et al., 2016; Park et al., 2018; Yang et al., 2017). > 80% of et al., 2001; Hayden et al., 2010; Hodges et al., 2003).
working-age people experience LBP at least once in their lives (Vujcic Individuals with LBP are recommended physiotherapy. The causes
et al., 2018). Research has highlighted the increased prevalence of LBP of LBP are varied with different exercise programs used to treat patients
among young and middle-aged people (Hoy et al., 2014). including aerobic exercise, muscle building, flexibility and stretching
In cases of LBP, reduced spinal segment mobility, decreased activity exercises (Gomes-Neto et al., 2017; Hayden et al., 2010; Lawand et al.,
and stamina of the deep trunk muscles (especially multiple and trans- 2015; Saragiotto et al., 2016).
verse abdominal, obliquus internus), and decreased multifidus muscle Most often they are prescribed a traditional muscle-strengthening
cross sectional area (CSA) are detected (Casser et al., 2016; Hides et al., program that strengthens large superficial back and abdominal muscles.
2008b). The shortcoming of such a program is the inability to target deep back
A sedentary lifestyle with a lack of physical activity results in the muscles and inappropriate waist stabilization (Cornwall et al., 2006;
loss of muscle power and strength and can be a predictor of LBP leading Kumar, 2011). Stability of lumbar spine segments is an important
to recurrent LBP (Citko et al., 2018). Continuous pressure on the in- component of the body biomechanics, and the lack of stability can af-
tervertebral disc and decreased metabolic exchange and disc nutrition fect the occurrence of LBP (Kumar, 2011). Currently there is a popular

⁎
Corresponding author at: Department of Applied Biology and Rehabilitation, Lithuanian Sports University, Sporto 6, Kaunas, Lithuania.
E-mail address: [email protected] (S. Sipaviciene).

https://doi.org/10.1016/j.clinbiomech.2019.12.028
Received 8 August 2019; Accepted 30 December 2019
0268-0033/ © 2020 Elsevier Ltd. All rights reserved.
S. Sipaviciene and I. Kliziene Clinical Biomechanics 73 (2020) 17–27

exercise program that uses spinal stabilization exercises to train deep the exercises. The exercises met suggested criteria for safety; these in-
pelvic floor muscles as well as back and transverse muscles (Gordon and cluded the avoidance of active hip flexion with fixed foot positioning
Bloxham, 2016; Ko et al., 2018; Kumar, 2011). and pulling with the hands behind the head and ensuring knee and hip
However, it remains unclear which exercise program has a greater flexion during all upper body exercises. Participants of the lumbar
effect and a longer lasting positive effect on people suffering from LBP muscle strengthening exercise program group performed the selected
and performing sedentary work. exercises which were used to improve trunk flexor (rectus abdominis)
The aim of this study was to assess the immediate effect and the and extensor (erector spinae) muscles strength. The participants needed
lasting effect of different exercise programs on lumbar muscle function, to perform from 8 to 16 repetitions of all exercises (Fig. 2).
cross-sectional area of the multifidus muscle, functional disability and The subjects were tested using a Biodex Medical System PRO 3
LBP in people performing sedentary work. dynamometer (certified ISO 9001 EN 46001; Shirley, NY, USA).
Isokinetic peak torque was measured at an angular velocity of 60°/s
2. Methods (Kliziene et al., 2016; Sekendiz et al., 2007). Mechanical brakes were
applied at 60° of amplitude in order to minimize unwanted movements
Seventy female volunteers suffering non-specific LBP were rando- (Den Hartog et al., 2010). Prior to testing, all subjects were familiarized
mized to either the lumbar stabilization exercise program group with the methodology of the assessment and then performed a standard
(n = 35) or the lumbar muscle strengthening exercise program group warm-up which involved exercising on the ergometer (Ergo-Fit Ergo
(n = 35). All subjects had been suffering from LBP for at least 12 weeks. Cycle 177, Pirmasens, Germany) at low intensity for 5 min (heart rate
The study did not include patients with neurological symptoms, spinal 110–130 beats/min). After warming up, the subjects sat in the Biodex
damage, cancer or infectious diseases that could lead to LBP or any System 3 PRO chair and remained quiet for 2 min. Shoulder, torso and
other diseases that could affect physical performance. Patients with thigh straps were used to maintain the angle between the waist and
myoparalysis, paraesthesia and psychological problems in addition to thigh at 90° (Kliziene et al., 2016). During the test the subjects were
patients who had trouble in performing exercise because of difficulties asked to minimize head movements and keep hands crossed on the
to understand were also excluded. None of the study participants had chest. After several practice movements followed by 5 min rest, vo-
undergone surgery for LBP. For 8 h/day participants performed se- lunteers performed maximal isokinetic voluntary trunk flexion invol-
dentary work, and their lifestyle was sedentary as well. The mean age of ving three trunk flexion and extension movements using maximal ef-
the lumbar stabilization exercise group subjects was 38.3 years (SD fort. For data analysis we used the value indicating the highest maximal
5.1 years), their body weight was 65.1 kg (SD 7.9 kg), height 168.3 cm force.
(SD 3.7 cm). The lumbar muscle strengthening exercise group com- Ultrasound scanning of the muscles was carried out using a TITAN™
prised women aged 38.5 years (SD 6.2 years), with a body weight of ultrasound system (SonoSite Inc., Bothell, WA, USA). Multifidus muscle
66.3 kg (SD 8.2 kg), and a height of 167.8 cm (SD 4.7 cm). The lumbar CSAs (cm2) was measured in the B-scan mode. The surfaces of the
stabilization exercise group subjects were enrolled in a 20-week ex- muscles, organs and blood vessels were imaged by the HST/10–5 MHz
ercise program to increase lumbar stability. The lumbar muscle 25 mm linear probe at a frequency of 10 MHz. The patients were lo-
strengthening exercise group subjects were enrolled in a 20-week ex- cated face down in a neutral and relaxed head position, with their arms
ercise program to increase lumbar muscle strength. None of the women resting at their sides. Lordosis of the lumbar spine was reduced by
had previously been involved in similar studies. All subjects were asked placing a small pillow under the abdomen. The ultrasound scanning of
not to use any medication, such as muscle relaxants, analgesics, or multifidus muscles was applied in parallel on both sides of the spine in
psychotropic drugs, for at least 4 days before testing. the L4–L5 region. The process of palpation was used to identify the
This study was approved by the Kaunas Regional Ethics Committee fourth lumbar vertebra (L4) starting from the wings of the hip bones
of Biomedical Research (Protocol No BE-10-15). Each volunteer read towards the centre line (Kliziene et al., 2015). Where the view of ul-
and signed the informed consent form before participation in the study. trasound image was brightest, the CSA of multifidus was measured by
Before starting the exercise program, after completing it and at 4, 8 tracing around the inner edge of the muscle boundaries. The CSA (cm2)
and 12 weeks after the intervention, the following tests were carried of lumbar multifidus muscle was measured according to method of
out: isokinetic peak torque at an angular velocity of 60°/s, measured Hides et al. (1992).
using a Biodex System 3 Pro isokinetic dynamometer; measurement of An ODI questionnaire was used to rate the effects of LBP intensity on
the cross-sectional area of the multifidus muscle, performed using a the patient's functional state in different life situations. Pain intensity
TITAN™ ultrasound system, and assessment using the Oswestry dis- was rated by applying a visual analogue pain scale (VAS) with a range
ability index (ODI), as well as visual analogue (VAS) rating scales. of 0 to 10 points, where 0 = no pain; 2 = mild pain; 4 = moderate
The exercise program was performed twice a week; the time period pain; 6 = severe pain; 8 = very severe pain; and 10 = unbearable pain.
of each session was 45 min. The exercise program endured for
20 weeks, therefore patients participated in a total of 40 exercise ses- 2.1. Statistical analysis
sions. The subjects performed exercises under the supervision of a re-
habilitation doctor and a physical therapist. The physical therapist The Shapiro-Wilk test was used to test all data for normal dis-
helped each subject to achieve the right exercise position. The programs tribution, and all data were observed to be normally distributed. A two-
were divided into three categories: warm up, main part and cool down. way mixed analysis ANOVA (general linear model) was used to regulate
Both warm up and cool down static and dynamic stretching exercises the effect of the exercise program as within subject factor of two levels,
were performed easy and without pain with amplitude of motion and within group (results before exercise program were compared with
lasted for 5 min. results immediately after exercise program and after 4, 8 and 12 weeks
The lumbar stabilization exercise program consisted of the selected post exercise program) and between groups (lumbar stabilization ex-
exercises which were used to strengthen the deep trunk stabilizing ercise group and lumbar muscle strengthening exercise group) at the
muscles (especially transverse abdominal, internal oblique and lumbar same time intervals. Pearson's correlation coefficients were determined
multifidus) and control pelvic muscles (Fig. 1). The participants needed by correlation analyzes after exercise program at the same time inter-
to perform from 8 to 16 repetitions of all exercises, except Hundred (100 vals between LBP and the maximum isometric trunk flexion strength,
repetitions), (Fig. 1). The lumbar stabilization exercise group subjects' CSA and ODI. Strong correlation 0.7–1.0, good correlation 0.5–0.7,
lumbar neutral spine position was controlled by the physiotherapist at moderate correlation 0.5–0.3 and poor correlation < 0.3 (Hazra and
the beginning of each exercise, and the subjects were asked to sustain Gogtay, 2016). The level of significance was set at P < 0.05. All sta-
this position all through the exercise. An identical order was applied to tistical analyses were performed using IBM SPSS Statistics ver. 22 (IBM

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S. Sipaviciene and I. Kliziene Clinical Biomechanics 73 (2020) 17–27

Spine curl. The starting position had to

be a relaxed position with neutral pelvis
and spine. Subjects had to breath in,
breath out and curl the pelvis from the
mat sequentially up from the mat vertebra
by vertebra rolling the spine. Then the
spine had to be rolled back to the neutral
position.

Roll down. Subjects had to lie down,

stretch arms above head and lower
shoulders. Subjects breathed in, activating
pelvic muscles and breathed out,
stretching arms forward. While tensing
bottom muscles with raised head and
lifting up from the carpet with rounded
back, raising one vertebra at a time.

Fig. 1. Lumbar stabilization exercise program

Note: The sequence of exercises: Spine curl; Roll down; Curl up; Rolling like a ball; Hundred; Cat; Side balance; Side band with rotation.

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S. Sipaviciene and I. Kliziene Clinical Biomechanics 73 (2020) 17–27

Curl up. Neutral spine and pelvis was

kept as starting position for subjects.
Inhalation was done while exhaling curl
spine, keeping head in the palms and
space between chin and chest, legs in one
line with hips, or in frog position.
Inhalation was done while lying down to
the starting position.

Rolling like a ball. In a seated position,

shins had to be hugged into chest and
sacrum balanced in order to lift feet off
the mat. Subject’s body had to be held in
a ball shape and knees remain shoulder
distance apart with the ankles close
together. Inhalation was done as rolling
back to shoulder blades. Exhalation was
done as rolling up to the start position,
maintaining the curve of the spine. The C-
curve shape of spine had to be
maintained. Head and neck had not to
touch the mat while rolling back.
Hundred. Subjects had to lie down on the
mat with legs pressed together. While
exhaling, head, shoulders and arms had to
be lifted up and both legs raised off the
mat to the desired height. Arms had to be
pumped for 100 times. Inhalation and
exhalation was done for five arm pumps.
The abdominals had to be kept drawn into
the mat and back remain flat on the mat.

Cat. The starting position for subjects

was four-point kneeling, while breathing
in and breathing out. Subjects had to roll
the pelvic underneath, flex and round the
lower back and continue this flexion to
allow upper back to round gradually
followed by the neck.

Fig. 1. (continued)

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S. Sipaviciene and I. Kliziene Clinical Biomechanics 73 (2020) 17–27

Side balance. Subjects had to lie on the

right side and correctly align pelvis and
spine, keeping head, neck and legs in line
with spine, connecting inner tights in
parallel with softly pointed feet. Subjects
had to inhale, exhale, lift both legs from
the mat to the level with the top of the
pelvis and maintain a stable and still
pelvis and spine for 10-20 sec. It was
repeated to the other side.

Side band with rotation. The starting

position was on the left side with hip,
knee and elbow in a line, keeping both
legs together with inner tights connected.
Subjects had to breathe in and maintain a
neutral pelvic and open top knee and arm,
keeping feet connected together. When
breathing out, subjects had to rotate the
spine to the mat, simultaneously reaching
with left arm the floor under the right
side. It was repeated to the other side.

Fig. 1. (continued)

Corporation, Armonk, NY, USA). 4. Discussion

In this study we established that after participating in a 20-week

3. Results exercise program, LBP and functional disability decreased in persons
with LBP.
After finishing the 20-week exercise programs, the LBP and ODI Many researchers have worked hard to find an appropriate special
scores decreased, maximal isokinetic trunk extension and flexion peak exercise program that will significantly reduce pain and increase
torque and multifidus muscle CSA values were significantly higher in functional capacity for people with LBP (Kim et al., 2018; Yang et al.,
both groups. The data showed significant differences compared with 2017). Only a few studies have directly compared a stabilization ex-
results before exercise program (baseline) and results immediately after ercise program with other exercise programs. Our study compared a
exercise program and after 4, 8 and 12 weeks post exercise program. lumbar stabilization exercise program with a muscle strength program
Significant changes were found between the lumbar stabilization ex- for patients with LBP. The lasting effect of the lumbar stabilization
ercise program and the lumbar muscle strengthening exercise program exercise program was more pronounced and lasting than the effect of
(Tables 1, 2 and 3). the strength exercise program. The positive effect (LBP, CSA) of the
After the completion of exercise programs, LBP significantly corre- lumbar stabilization exercise program persisted for 12 weeks. With the
lated with the maximum isometric trunk flexion strength, CSA and ODI aim of comparing our results with those of other researchers we re-
(Table 4). viewed many of the studies dealing with this issue and found a variety

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S. Sipaviciene and I. Kliziene Clinical Biomechanics 73 (2020) 17–27

Sit-up. Subjects had to lie with their back

on the floor, with hands behind the head
and the knees bent. Then they curled
upper body toward their knees and
lowered down returning to starting
position

Sit-up with both legs up. In a supine

position on the floor with hands behind
the head, knees flexed at 90 deg, and feet
flat on the floor, the subjects were
instructed to raise the upper torso up to a
45 deg without the curling-up movement.
Subjects had to lift the upper body and
legs, changing legs and sides.

Sit-up with changing legs and sides. In

a supine position on the floor with hands
behind the head, knees flexed at 90 deg,
the subjects were instructed to raise the
upper torso up to a 45 deg without the
curling-up movement. Subjects had to lift
the upper body and legs, changing legs
and sides.

Fig. 2. Trunk muscle-strengthening exercise program

Note: The sequence of exercises: Sit-up; Sit-up with both legs up; Sit-up with changing legs and sides; Sit-up with legs up; Cross sit-up; Side plank clam; Prone plank;
Push up.

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S. Sipaviciene and I. Kliziene Clinical Biomechanics 73 (2020) 17–27

Sit-up with legs up. In a supine position

on the floor with hands behind the head,
knees flexed at 90 deg, and feet flat on the
floor, the subjects were instructed to raise
the upper torso up to a 45 deg without the
curling-up movement. Subjects had to lift
the upper body and legs up.

Cross sit-up. Subjects had to lie on the

floor with knees flexed at 90 deg. Bent
left leg lifted on right knee, with hands
behind the head and elbows opened
wide. Then curled upper body toward
left knee. Right elbow had to touch left
knee. Then lowered down returning to
starting position, changing legs and
sides.

Side plank clam. Subjects had to set up

on side propped up on forearm with
elbow underneath shoulder. Knees had
to be bended so that feet and lower legs
were behind. Then bottom hip had to be
lifted up off the ground, driving through
knee and forearm. Top leg had to be
lifted up and toward the ceiling, keeping
the knee bent. Subjects had to keep legs
open, lifting top knee toward the ceiling.

Fig. 2. (continued)

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S. Sipaviciene and I. Kliziene Clinical Biomechanics 73 (2020) 17–27

Prone plank. In a prone position on the

floor with the elbow angle at 90 deg (180
= full extension) and the forearms placed
underneath the chest, pelvis raised off the
floor and body weight distributed on the
forearms and toes, the subjects were
instructed to maintain a flat position.

Push up. Subjects had to get into a

push-up position, supporting body on
hands. Exhalation was done as subjects
extended their elbows and pushed bodies
back up to the starting position.

Fig. 2. (continued)

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S. Sipaviciene and I. Kliziene Clinical Biomechanics 73 (2020) 17–27

Table 1
Values of maximal isokinetic trunk extension and flexion peak torque (Nm).
Extension Flexion

Stabilization group Strengthening group Stabilization group Strengthening group

Baseline 133.1 (SD 9.6) 132.1 (SD 7.4) 91.7 (SD 8.3) 89.9 (SD 9.1)
Post intervention exercise program 214.1 (SD 7.3)⁎,# 239.3 (SD 7.7)⁎ 122.6 (SD 9.2)⁎,# 147.9 (SD 8.5)⁎
4 weeks post exercise program 199.8 (SD 6.1)⁎,# 219.9 (SD 7.2)⁎ 111.3 (SD 4.7)⁎,# 134.8 (SD 9.8)⁎
8 weeks post exercise program 174.4 (SD 8.3)⁎ 179.5 (SD 7.1)⁎ 104.1 (SD 9.2)⁎ 115.3 (SD 6.3)⁎
12 weeks post exercise program 147.2 (SD 8.1) 142.3 (SD 9.2) 98.1 (SD 7.6) 99.6 (SD 5.5)

⁎
Data before exercise program (baseline) for each group was compared separately with data of post intervention and data after 4, 8 and 12 weeks post exercise
program, P < 0.001.
#
Data before exercise program (baseline), post intervention data and data after 4, 8 and 12 weeks post exercise program, was compared between groups,
P < 0.05).

of results. In previous studies the duration was different, for example CSA of the multifidus muscles decreases (Fortin and Macedo, 2013;
involving a lumbar stabilization exercise program lasting 4, 6, 10, 12, Hides et al., 2008a; Kamaz et al., 2007). Paraspinal muscle atrophy is
16 or 20 weeks, and this could have influenced the results (Cho et al., significant in predicting long-term LBP (Fortin et al., 2015). For persons
2014; Goldby et al., 2006; Kliziene et al., 2015; Kliziene et al., 2016; with LBP, the highest CSA decrease occurs in the multifidus and para-
Smith et al., 2011; Stuge et al., 2004). The results reported by other spinal muscles (Goubert et al., 2016).
researchers showed that a 20-week stabilization exercise program was In persons with LBP, weakened trunk muscles are seen when mea-
more effective in reducing the level of LBP and disability than an ex- suring isometric or isokinetic contraction and their lumbar extensor
ercise program without stabilization exercises, and this positive effect muscle endurance is also decreased (Cho et al., 2014). The result of
was maintained even after a year's break (Stuge et al., 2004). The re- muscle strength and stamina decrease is muscle atrophy. Thus, mus-
sults of previous studies have shown that 24 weeks after finishing a cular atrophy requires the use of therapy and we applied physical ex-
program of spinal stabilization exercises, LBP recurred in 30% of sub- ercises. After 20 weeks of physical exercise, we established a significant
jects, while in the control group who underwent a conventional phy- increase in lumbar muscle strength that lasted for 12 weeks after the
siotherapy program, LBP returned in 84% of patients (Hides et al., program completion. The intensity of LBP in subjects significantly
2008a; Hides et al., 2008b). Thus, the effects of stabilization exercises correlated with maximal isokinetic trunk flexion strength immediately
persist longer than those of manual therapy or healthy behaviour after the exercise program and 4 weeks after the intervention. It is
learning, but in some patients, pain returns once the patient stops possible that the initial results of lumbar muscle strength were influ-
performing the exercises (Goldby et al., 2006). enced by the LBP felt by subjects. Therefore, motor control might be
Our study involved women who had sedentary jobs and were not significantly different because the activity of the agonist muscles de-
previously engaged in sports activities. Research shows that employees creases while that of the antagonist muscles increases thus reducing the
who spend most of their working time being sedentary suffer from LBP speed, strength and amplitude of movements when pain occurs
(Korshøj et al., 2018; Lunde et al., 2017). In the sitting position, the (Hodges, 2001).
muscles of the whole body are not very active, so long periods sitting Our research results showed that CSA increased after 20 weeks of
and reduced muscle activity leads to an increased load on the inter- both exercise programs. However, after spinal stabilization exercises a
vertebral discs, which leads to a change in the natural spine curvature significant increase was shown in CSA and this positive effect lasted for
and weakening of the paravertebral muscles attached to the vertebrae, 12 weeks after the end of the exercise program. Previous studies have
resulting in degenerative spinal processes (Yamauchi et al., 2015). For shown that after 10 weeks of stabilization training with dynamic static
people with low physical activity levels, muscle function is weakened, resistance exercise, lumbar multifidus muscle CSA increased in persons
i.e. muscle deconditioning occurs (Steele et al., 2014). Complex loads with cLBP (Danneels et al., 2001). Spinal stabilization exercises have a
affect passive spinal ligament structures and in case of inadequate spine statistically significant effect on LBP reduction, and a statistically-sig-
protection, lumbar spine damage increases (Stevens et al., 2007). In nificant increase in cross-sectional area was obtained by estimating the
cases of LBP, specific acute or chronic processes take place in the trunk lumbar muscle cross-sectional area at L5 level (Hides et al., 2008a).
muscles that reduce muscle CSA (Fortin and Macedo, 2013). This is a Other studies have shown that an 8-week spinal stabilization exercise
localized specific muscle response to reduced muscle activity. After program reduces lumbar muscle atrophy, reduces pain, disability levels,
prolonged physical inactivity, paraspinal muscle atrophy occurs and the and increases trunk muscle strength in LBP patients (Kalichman et al.,

Table 2
Values of cross-sectional area (cm2) of the lumbar multifidus muscles.
Right side Left side

Stabilization group Strengthening group Stabilization group Strengthening group

Baseline 5.0 (SD 0.7) 5.1 (SD 0.3) 4.9 (SD 0.9) 5.0 (SD 0.4)
Post intervention exercise program 8.1 (SD 0.3)⁎,# 5.6 (SD 0.9)⁎⁎ 8.2 (SD 0.2)⁎,# 5.7 (SD) 0.6⁎⁎
4 weeks post exercise program 7.6 (SD 0.7)⁎,# 5.4 (SD 0.6)⁎⁎ 7.7 (SD 0.5)⁎,# 5.4 (SD 0.3)⁎⁎
8 weeks post exercise program 7.2 (SD 0.3)⁎,# 5.2 (SD 0.7) 7.3 (SD 0.4)⁎,# 5.2 (SD 0.9)
12 weeks post exercise program 6.1 (SD 0.5)⁎,# 5.1 (SD 0.9) 6.4 (SD 0.6)⁎,# 5.1 (SD 0.9)

⁎
Data before exercise program (baseline) for each group was compared separately with data of post intervention and data after 4, 8 and 12 weeks post exercise
program, P < 0.001.
⁎⁎
P < 0.05.
#
Data before exercise program (baseline), post intervention data and data after 4, 8 and 12 weeks post exercise program, was compared between groups,
P < 0.05).

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S. Sipaviciene and I. Kliziene Clinical Biomechanics 73 (2020) 17–27

Table 3
Oswestry disability index and low back pain intensity (scores).
Oswestry disability index Low back pain

Stabilization group Strengthening group Stabilization group Strengthening group

Baseline 22.3 (SD 07) 21.6 (SD 0.3) 5.5 (SD 0.3) 5.4 (SD 0.2)
Post intervention exercise program 7.8 (SD 0.3)⁎,# 9.4 (SD 0.9)⁎ 1.3 (SD 0.02)⁎,# 1.4 (SD 0.03)⁎
4 weeks post exercise program 8.6 (SD 0.7)⁎,# 11.2 (SD 0.6)⁎ 1.7 (SD 0.05)⁎,# 2.6 (SD 0.06)⁎
8 weeks post exercise program 9.5 (SD 0.3)⁎,# 16.3 (SD 0.7) 3.4 (SD 0.2)⁎,# 5.1 (SD 0.8)
12 weeks post exercise program 11.4 (SD 0.5)⁎,# 17.6 (SD 0.9) 4.2 (SD 0.1)⁎,# 5.3 (SD 0.7)

⁎
Data before exercise program (baseline) for each group was compared separately with data of post intervention and data after 4, 8 and 12 weeks post exercise
program, P < 0.05.
#
Data before exercise program (baseline), post intervention data and data after 4, 8 and 12 weeks post exercise program, was compared between groups,
P < 0.05).

2017). However, other researchers believe that there is a lack of evi- been resolved and further research is needed. An overview of our re-
dence of a causal relationship between changes in strength or CSA and search data suggests that regular lumbar stabilization exercise programs
pain, disability, and specific treatment for LBP (Valdivieso et al., 2018). improve trunk stability and mobility, strengthen trunk muscles, de-
It has been observed that the relationship between pain and muscle crease LBP, and improve lumbar spine functionality. Both exercise
strength is evident when weaker paraspinal muscles do not protect the programs, lumbar stabilization exercise and muscle strengthening ex-
spine and pelvic structure from excessive load and damage in daily ercise, decreased LBP and functional disability and increased lumbar
movements or sports activities (Valdivieso et al., 2018). In individuals muscle strength. However, the lumbar stabilization exercise program
with LBP, the spinal stabilization function of the deep trunk muscles, was more effective and its positive effects were more lasting for persons
inter-muscular coordination, nerve control and the accuracy of pro- with LBP and who performing sedentary work. We established that
prioceptive information are reduced (Hides et al., 2008a). reduced LBP and functional disability as well as increased multifidus
LBP associated with musculoskeletal disorders is reduced by treat- muscle CSA persist for 12 weeks, while the increased trunk muscle peak
ments that affect muscle strength and endurance (Steele and Bruce- torque remains 8 weeks after completion of the lumbar stabilization
Low, 2012). Lumbar spinal stability is one of the most important goals exercise program which lasted for 20 weeks.
of LBP treatment (Grenier and McGill, 2007). For individuals with LBP The limitation of this study is its short duration, as the long-term
who performed spinal stabilization exercises which restored the func- effects of a lumbar stabilization exercise program in persons with LBP
tion of the deep trunk muscles, back pain was less frequent afterwards remain unknown after 24 weeks of suspended exercises.
than in those who did not receive therapy involving these exercises
(Hides et al., 2011). Traditional exercise programs used for the treat-
ment of LBP include strengthening and stretching the large superficial 5. Conclusion
back and abdominal muscles, but they do not include stabilization ex-
ercises. The disadvantage of such programs is the inability to activate The 20-week lumbar stabilization exercise and muscle strength-
the deepest back muscle layers as well as inappropriate pelvic im- ening exercise programs were efficacious in decreasing LBP and func-
mobilization, which can cause injury during exercise (Cairns et al., tional disability in people performing sedentary work, however the
2006; McGill et al., 2003). lumbar stabilization exercise program was more effective, and this ef-
We also observed a relationship between LBP and ODI, so we can fect lasted for 12 weeks after completion of the program.
assume that it is possible to significantly reduce functional disability
while attempting to ameliorate LBP. When individuals who suffer from Acknowledgements
LBP have control over their trunk muscles performing functional tasks,
this reduces daily activity limitations and improves their overall well- We would like to thank to those who took part in this study.
being (Hides et al., 2011).
Exercises that focus on deep stabilizing muscles as well as stretching
and relaxation exercises form an effective and safe rehabilitation tool Declaration of competing interest
that reduces the patient's LBP (Tomanova et al., 2015). After reviewing
many other research publications, we believe that this issue has not The authors declare that they have no conflict of interest.

Table 4
Correlation relationship between low back pain intensity and the cross-sectional area of the lumbar multifidus muscles, Oswestry disability index and maximal
isokinetic trunk flexion peak torque.
Cross-sectional area Oswestry disability index Isokinetic flexion peak torque

Stabilization group Strengthening group Stabilization group Strengthening group Stabilization group Strengthening group

Pain post intervention exercise program r = −0.691 r = −0.652 r = 0.603 r = 0.614 r = −0,625 r = −0.652
P = 0.035⁎ P = 0.041⁎ P = 0,041⁎ P = 0.043⁎ P = 0.045⁎ P = 0.035⁎
Pain after 4 weeks post exercise program r = −0.682 r = −0.361 – – r = −0.515 r = −0.542
P = 0.041⁎ P = 0.048⁎ – – P = 0.044⁎ P = 0.046⁎
Pain after 8 weeks post exercise program r = −0.663 – – – – –
P = 0.042⁎ – – – – –
Pain after 12 weeks post exercise program r = −0.591 – – – – –
P = 0.044⁎ – – – – –

Note: Only statistically significant values of correlation coefficients are shown in the table.
⁎
P < 0.05 by correlation analysis.

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S. Sipaviciene and I. Kliziene Clinical Biomechanics 73 (2020) 17–27

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