Efficacy of core muscle strengthening exercise in chronic low back pain patients

Abstract

Abstract
BACKGROUND AND OBJECTIVES:
Low back pain is a common health problem in human being and about 5 to 15% will develop chronic low back pain (CLBP). The clinical findings of CLBP suggest that lumbar mobility is decreased and recruitment order of core muscles is altered. In literature, there is no data about the effect of core muscles strengthening in the chronicity (short duration, long duration) of CLBP. This study evaluated the effect of core muscle strengthening intervention on chronicity of chronic low back pain.METHOD: Thirty patents were recruited from the outpatient department of the National Institute for the Orthopedically Handicapped. These 30 patients were divided into two groups: A and B on the basis of duration of low back pain. Group-A patients complain about pain duration for more than twelve months and Group B complains about pain duration from three to twelve months. Both the groups were received same intervention for six weeks. Assessment was done pre intervention and post intervention after six weeks for both the groups. For both the groups the assessment was done after six weeks for pre and post intervention.
RESULTS:
The result described both the groups showed improvement in all the outcome measures including pain as well as in function using Numerical pain rating scale, Oswestry Disability Index, Sorensen test, Gluteus Maximus Strength, Activation of transversus abdominis and Modified-Modified Schober's Test. The improvement was statistically non-significant with inter groups and significant within group.CONCLUSION: This study concludes that core muscle strengthening exercise along with lumbar flexibility and gluteus maximus strengthening is an effective rehabilitation technique for all chronic low back pain patients irrespective of different duration (less than one year and more than one year) of their pain.
KEYWORDS:
Chronic low back pain; Gluteus maximus strengthening; core muscle strengthening; lumbar flexibility; pressure biofeedback unit
PMID: 25467999 [PubMed - as supplied by publisher]

Full text

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Journal of Back and Musculoskeletal Rehabilitation 00 (2014) 1–9 1
DOI 10.3233/BMR-140572
IOS Press
Efficacy of core muscle strengthening
exercise in chronic low back pain patients
Tarun Kumara,SurajKumar
b,∗, Md. Nezamuddincand V. P. Sharmad
aDepartment of Physiotherapy, NIOH, Kolkata, India
bDepartment of Physiotherapy, Paramedical vigyan mahavidyalaya, UPRIMS&R, Saifai, Etawah, Uttar Pradesh,
India
cDepartment of Physiotherapy, NIOH, Kolkata, India
dDepartment of PMR, CSM Medical University, Lucknow, India
Abstract.
BACKGROUND AND OBJECTIVES: Low back pain is a common health problem in human being and about 5 to 15% will
develop chronic low back pain (CLBP). The clinical findings of CLBP suggest that lumbar mobility is decreased and recruitment
order of core muscles is altered. In literature, there is no data about the effect of core muscles strengthening in the chronicity
(short duration, long duration) of CLBP. This study evaluated the effect of core muscle strengthening intervention on chronicity
of chronic low back pain.
METHOD: Thirty patents were recruited from the outpatient department of the National Institute for the Orthopedically Hand-
icapped. These 30 patients were divided into two groups: A and B on the basis of duration of low back pain. Group-A patients
complain about pain duration for more than twelve months and Group B complains about pain duration from three to twelve
months. Both the groups were received same intervention for six weeks. Assessment was done pre intervention and post in-
tervention after six weeks for both the groups. For both the groups the assessment was done after six weeks for pre and post
intervention.
RESULTS: The result described both the groups showed improvement in all the outcome measures including pain as well as
in function using Numerical pain rating scale, Oswestry Disability Index, Sorensen test, Gluteus Maximus Strength, Activation
of transversus abdominis and Modified-Modified Schober’s Test. The improvement was statistically non-significant with inter
groups and significant within group.
CONCLUSION: This study concludes that core muscle strengthening exercise along with lumbar flexibility and gluteus max-
imus strengthening is an effective rehabilitation technique for all chronic low back pain patients irrespective of different duration
(less than one year and more than one year) of their pain.
Keywords: Chronic low back pain, pressure biofeedback unit, core muscle strengthening, lumbar flexibility, Gluteus maximus
strengthening
1. Introduction1
Low back pain (LBP) is a common health prob-2
lem in all developed countries and is most commonly3
treated in primary healthcare setting. There is a life-4
∗Corresponding author: Suraj Kumar, Department of Physiother-
apy, Uttar Pradesh Rural Institute of Medical Sciences and Research,
Paramedical Vigyan Mahavidyalaya, Saifai, Etawah, UP – 206301,
India. Mobile No. 7830337168; E-mail: Surajdr2001@yahoo.com.
time prevalence of 35–40% for cervical pain, 11–15% 5
for thoracic pain 60–70% for lumbar pain, and 15% for 6
pelvic pain [1,2] and the recurrence rate of low back 7
pain is 80% [3]. It is estimated that 80–90% of pa- 8
tients recover within 6 weeks, regardless of treatment. 9
However, 5–15% will develop chronic low back pain 10
(CLBP) [4]. 11
The “core” has been described as a muscular box 12
with the abdominals in the front, paraspinals and 13
gluteals in the back, the diaphragm as the roof, and 14
ISSN 1053-8127/14/$27.50 c
2014 – IOS Press and the authors. All rights reserved

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2T. Kumar et al. / Efficacy of core muscle strengthening exercise in chronic low back pain patients
the pelvic floor and hip girdle musculature as the bot-15
tom [5]. Bergmark [6] divided the trunk muscles into16
two groups – a local and a global system of muscles17
engaged in the equilibrium of the lumbar spine. The18
local system consists of muscles with insertion or ori-19
gin (or both) at lumbar vertebrae, whereas the global20
system consists of muscles with origin on the pelvis21
and insertions on the thoracic cage. The anatomical,22
biomechanical and physiological features muscles may23
be categorized into two groups, stabilizers and mobi-24
lizers. The structural and functional characteristics of25
the two muscle categories make the stabilizers better26
equipped for postural holding with an ‘anti-gravity’27
function. The mobilizers are better set up for rapid bal-28
listic movementsand are often referred to as ‘task mus-29
cles’. In the case of the abdominal muscles, the rectus30
abdominis and lateral fibres of external oblique may be31
considered as the prime movers (mobilizers) of trunk32
flexion, and erector spinae is trunk extensor while the33
internal oblique, multifidus and transversusabdominis34
are the major stabilizers of trunk movement in gen-35
eral [7]. Further categorization may be made into pri-36
mary and secondary stabilizers. The primary stabiliz-37
ers are those muscles which cannot create significant38
joint movements, such as the lumbar multifidus (LM)39
and transversus abdominis (TrA). These muscles act40
only to stabilize. The secondary stabilizers, such as the41
internal oblique, medial fibres of external oblique and42
quadratus lumborum have excellent stabilizing capac-43
ity, but may also move joints. Taking this categoriza-44
tion further, mobilizers could be termed ‘tertiary sta-45
bilizers’ in that they primarily move the joint, but can46
stabilize in times of extreme need, an example being47
muscle spasm in the presence of pain. In this situation,48
however,stability has moved on to become rigidity and49
does not allow normal movement patterns [8].The ac-50
tivity of the gluteus maximus muscle is reduced in pa-51
tients with CLBP [9–12].52
Chronic low back pain (CLBP) is a complex con-53
dition which is mainly associated with back (multi-54
fidus) [13–19], abdominal (transversusabdominis) [12,55
16–19] and hip (gluteus maximus) [9–11] muscles dys-56
function along with reduced lumbar flexibility [8].57
Transversus abdominis directly attached to the tho-58
racolumbar fascia (TLF), the weakness of this muscles59
decrease the shear strain of the TLF. The function of60
TLF is to increase the intra-abdominal pressure (IAP).61
Increase IAP may contributeto both unloading and sta-62
bilization of the lumbar spine [28] so that, in weakness63
of TrA the IAP decreases and lumbar spines becomes64
unstable and produced loading on lumbar spines.65
Thus core muscle stabilization training [4,14,16,19– 66
21,24,25,56] is recommended for treatment of CLBP. 67
Richardson et al [42] divided the core muscle strength- 68
ening in to three stages on the principles of ‘segmental 69
stabilization exercises model’. This was on the basis of 70
motor relearning principle, these exercises stages are 71
first Local segmental control then Close chain segmen- 72
tal control and finally Open chain segmental control 73
and progression into function. 74
The purpose of study was to find out the effect of 75
core muscle strengthening, lumbar flexibility and glu- 76
teus maximus strengthening in patients with chronic 77
lowback pain using pain and function using Numerical 78
pain rating scale, lumbar flexibility, Oswestry Disabil- 79
ity Index, Sorensen test, Gluteus Maximus Strength, 80
Activation of transversus abdominis and Modified- 81
Modified Schober’s Test, between long duration CLBP 82
(more than one year) and short duration CLBP (less 83
than one year). We hypothesise that the shot duration 84
CLBP group would improve faster than the long dura- 85
tion CLBP. 86
2. Methods 87
2.1. Subjects 88
A total 30 patients of non-specific CLBP of both 89
gender, were aged 20–40, with pain felt between T12 90
and inferior Gluteal fold with numericalpain rating 91
scores between 3 to 6 and no neurological deficits 92
were included from the National Institute for the Or- 93
thopaedically Handicapped (NIOH), B.T. Road, Bon- 94
Hooghly, Kolkata, India. In this study, 30 patients 95
were divided into two different groups on the basis 96
of duration of LBP. Patients in Group-A had pain for 97
more than 12 months and in Group-B had pain be- 98
tween 3 and 12-months. Those subjects who had his- 99
tory of any lumbar spine surgery, infection, vascular 100
problem, history of spinal exercises at least 12 weeks 101
before the onset of study, receiving steroid injec- 102
tion within previous 3 months and pregnancy, non- 103
mechanical LBP (no relief with bed rest), with sys- 104
temic disorder and history of malignancy were ex- 105
cluded. They were also excluded if they had LBP 106
less than three month. The study was approved by 107
the Institutional Ethical committee (Review letter no.: 108
IEC/1610/R&D/08/NIOH/458). Informed consent was 109
obtained from all patients included in the study. 110
2.2. Approach 111
Using ‘stratified sampling’, two groups were formed 112
on the basis of duration of pain. The outcome measures 113

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T. Kumar et al. / Efficacy of core muscle strengthening exercise in chronic low back pain patients 3
were pain intensity, functional ability, back endurance,114
lumbar flexibility, TrA and Gluteus Maximus strength.115
The baseline data recorded on day 0 (zero) and follow116
up after 6 weeks. All of these were assessed by same117
test procedure. Test and retest of each group were con-118
ducted in the same place and at same time of the day.119
2.3. Procedure120
All subjects were treated by the same physiothera-121
pist with the same intensity and capacity on alternate122
(3 days/week) for 6 weeks. The duration of each in-123
dividual treatment was depending on stages of treat-124
ment protocol. The treatment protocol included warm125
up, flexibility and core muscle strengthening exercises.126
Ten minute warm-up by bicycle or normal walk, flex-127
ibility exercises included knee to chest in supine, cat-128
camel, trunk side flexion in standing, trunk rotation in129
crook lying. The exercises of core muscle strengthen-130
ing in stage (1) comprised of local segmental control131
and activation of TrA with the help of pressure biofeed-132
back. In stage (2) exercises included close chain seg-133
mental control, upper quadrant close chain exercise,134
trunk forward lean and weight bearing (closed chain)135
exercise in flexed posture. In stage (3), the regimen136
consisted of open chain segmental control, lower limb137
activity maintaining lumbar spine stable using PBU138
as feedback. Gluteus maximus strengthening first con-139
sisted of corrected recruitment order and then strength-140
ening by single limb squat and single limb dead lift.141
The subjects were not allowed to take any other treat-142
ment and medication during the treatment.143
2.4. Outcome variable144
The level of pain intensity was assessed by nu-145
merical pain rating scale (NPRS) that is a 10 points146
scale., The functional ability was assessed accord-147
ing to Oswestry Disability Index, back endurance by148
Sorensen test (trunk holding time), lumber flexibility149
by Modified-Modified Schober’s test, Gluteus Max-150
imus strength by Jamar Hydraulic Hand Dynamometer151
and activation of Transversus abdominis with pressure152
biofeedback unit. The measuring details of variables in153
brief are summarized as follows.154
2.4.1. Numerical pain rating scale (NPRS) [32,33]155
This is the 10 point scale with 0 representing No156
Pain, 1–3 representing Mild Pain (nagging, annoying,157
interfering little with ADLs), 4–6 representing Mod-158
erate Pain (interferes significantly with ADLs), 7–10 159
representing Severe Pain (disabling; unable to perform 160
ADLs). The subject’s been asked to make a mark and 161
selected the number that best represents his/her inten- 162
sity of pain experienced on the same day [57]. 163
2.4.2. Oswestry disability index [35] 164
The Oswestry Disability Index (also known as the 165
Oswestry Low Back Pain Disability Questionnaire) is 166
an extremely important tool that researchers and dis- 167
ability evaluators use to measure a patient’s permanent 168
functional disability. The test is considered the ‘gold 169
standard’ of low back functional outcome tools [?]. 170
This scale contain question related to functional activ- 171
ities of pain intensity, personal care, lifting, walking, 172
sitting, standing, sleeping, sex life, social life and trav- 173
elling. For the understanding of ODI to the local popu- 174
lation it translated into local language (Bengali). Inter- 175
pretation of scale are 0% to 20% for minimal disabil- 176
ity, 21% to 40% for moderate disability, 41 % to 60 % 177
for severe disability 61% to 80 % for crippled and 81 178
% to 100 %. Bed-bound. 179
2.4.3. Sorensen test [36] 180
Biering-Sorenson describes this method of testing 181
isometric back endurance; it measures how long (to 182
a maximum of 240 seconds) the subject can keep the 183
unsupported trunk (from the upper border of the iliac 184
crest) horizontal while prone on an examination table. 185
During the test, the buttocks and legs are fixed to the 186
table by 3 wide canvas straps and the arms are folded 187
across the chest. The subject is asked to maintain the 188
horizontal position until he or she can no longercontrol 189
the posture or has no more tolerance for the procedure 190
or until symptoms of fatigue are reached. 191
2.4.4. Pressure biofeedback unit [37] 192
The pressure biofeedback unit consists of an inelas- 193
tic, three-section air-filled bag, which is inflated to fill 194
the space between the target body area and a firm sur- 195
face, and a pressure dial for monitoring the pressure in 196
the bag for feedback on position The bag is inflated to 197
an appropriate level for the purpose and the pressure 198
recorded. Quite simply, movement of the body part off 199
the bag results in a decrease in pressure, while move- 200
ment of the body part onto the bag results in an increase 201
in pressure. Pressure change uses as a diagnostic and 202
therapeutic uses. 203

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4T. Kumar et al. / Efficacy of core muscle strengthening exercise in chronic low back pain patients
Tab le 1
Compare the Demographic data at base line
Group-1 Group-2 Independent t-test
tP
Age (Mean ±SD) 30.47 ±7.16 33.2667 ±5.30 1.201 0.240
Height (Mean ±SD) 161.13 ±10.18 164.47 ±6.11 1.087 0.286
Weight (Mean ±SD) 62.80 ±12.23 65 ±7.121 0.602 0.552
BMI (Mean ±SD) 24.20 ±3.85 24.00 ±2.39 0.171 0.866
2.4.5. Modified-Modified Schober’s test [31]204
Modified-Modified Schober’s test for measures the205
flexibility of lumbar spine, patient standing, with cer-206
vical, thoracic and lumbar spine in 0 degrees of lat-207
eral flexion and rotation. Stabilize the pelvic to prevent208
anterior tilting. Ask the patient to bend forward as far209
as possible while keeping the knee straight. The thera-210
pist stands behind the patient and identifies the poste-211
rior superior iliac spines (PSISs) by marking the PSISs212
with his or her thumbs. Make an ink mark on the mid-213
line of the lumbar spines horizontal to the PSIS. Make214
another mark 15 cm superior just above the midline of215
the PSIS. Align the tape measure between the two skin216
marks, with zero at the inferior skin mark and 15 cm at217
the superior skin mark. Keep the tape measure firmly218
against the patient’s skin while the patient bends for-219
ward. When the patient has bent forward, the new dis-220
tance between the superior and inferior skin markings221
is measured with the patient positioned in full lumbar222
flexion. Flexion range of motion is the difference be-223
tween the initial length between skin markings (15 cm)224
and the length measured in full forward flexion.225
2.4.6. Jamar Hydraulic Hand226
Dynamometer(JHHD) [30]227
The gluteus maximus strength was measured by us-228
ing Jamar Hydraulic Hand dynamometer [12,30]. The229
readings were taken at baseline and at the end of in-230
tervention. Patient lie prone head on the hands, tested231
knee flexed to 90 degree and hip laterally rotated,232
placed the JHHD on femur at 10 cm from lateral joint233
line of knee. Measurement of maximum voluntarily234
isometric contraction of hip extension was taken.235
2.4.7. Statistical analysis236
A pre-test post-test experimental group design was237
used for the study. The baseline values for all de-238
pendent variables of pain, lumbar flexibility, back en-239
durance, contraction of TrA, strength of gluteus max-240
imus and function outcome were taken on day 0 (des-241
ignated as NPRS-0, MMS-0, SOR-0, PBU-0, JHHD-0242
and ODI-0 respectively).The final readings were taken243
at the end of 6 weeks (designated as NPRS-1, MMS-1,244
Tab le 2
Shown the baseline reading (0 days) and post- test reading (6 weeks).
Figure represent graphical presentation of improvement of each of
six variables score in both groups
S.NO Group-1 Group-2
NPRS Pre-5.67 ±0.488 Pre 5.67 ±1.047
Post-0.47 ±0.516 Post-1.047 ±0.594
PBU Pre-0.80 ±1.012 Pre 1.07 ±1.077
Post-6.67 ±0.967 Post-6.53 ±1.187
JHHD Rt. Pre-25.60 ±5.501 Pre 24.60 ±4.102
Post-27.47 ±5.343 Post-27.67 ±4.435
JHHD Lt Pre-22.27 ±5.007 Pre 22.67 ±3.904
Post-24.73 ±5.007 Post-25.87 ±4.533
MMS Pre-4.73 ±1.438 Pre 5.33 ±1.113
Post-7.80 ±0.775 Post-7.93 ±0.799
SORENSEN Pre-31.93 ±12.686 Pre 40.67 ±24.394
Post-133.93 ±18.234 Post-139.20 ±19.943
ODI Pre-54.20 ±14.610 Pre 51.47 ±16.552
Post-6.80 ±6.270 Post-8.13 ±6.679
SOR-1, PBU-1, JHHD-1 and ODI-1).Statistical anal- 245
ysis IBM SPSS statistical 20, MS EXCEL and MS 246
Office 97–2003 during the analysis of study. A two- 247
tailed probability (P) value between 0.05 (P<0.05) 248
and 0.01 were considered statistically significant; P< 249
0.01 as highly significant and P>0.05 had no signifi- 250
cance (ns). Paired t test was applied for comparison of 251
NPRS, MMS, SOR, PBU, JHHD and ODI within the 252
groups (inter-group) and between groups (intra-group). 253
All dependent variables were compared between base- 254
line and the value at end of 6 weeks. 255
3. Results 256
3.1. Distribution of subjects 257
The values of Age, Height, Weight and BMI indi- 258
cates that there was no statistically significant differ- 259
ence between Group A and B at baseline. The regis- 260
tered ‘p’ values of Age, Height, Weight and BMI was 261
0.240, 0.286, 0.552 and 0.866 respectively. These show 262
that both groups were homogenous and the baselines 263
were comparable (Table 1). 264
3.2. Outcome measures 265
The pre and post outcome measures data were sum- 266

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T. Kumar et al. / Efficacy of core muscle strengthening exercise in chronic low back pain patients 5
0
1
2
3
4
5
6
7
8
9
N
5.67
0.47
PRS Gp-1
5.67
1.047
NPRS Gp-2
0.8
6.67
PBU Gp-
Pre Value
1.07
-1 PBU G
Post V
4.7
6.53
p-2 MM
alue
73
7.8
SGp-1
5.33
7.93
MMS Gp-2
Fig. 1. Graphical presentation of improvement of each of six vari-
ables score in both groups. (Colours are visible in the online version
of the article; http://dx.doi.org/10.3233/BMR-140572)
0
20
40
60
80
100
120
140
160
25.6627.47 24.6 27.67 22.2724.73
Prt
e
22.67
.
24.6
e
value Po
s
133.93
s
t value
54.2
139.2
51.47
6.8 8.13
31.91
40.67
Gp-1
Gp-2
Gp-1
Gp-2
Gp-1
HHD Rt.
HHD Rt.
0DI
HHD Lt.
HHD Lt.
0DI Gp-2
SORENSESEN Gp-1
SORENSESEN Gp-2
Fig. 2. Graphical presentation of improvement of each of six vari-
ables score in both groups. (Colours are visible in the online version
of the article; http://dx.doi.org/10.3233/BMR-140572)
marised in Table 2 and also shown graphically in Figs 1267
and 2. The ‘student t-test’ showed p<0.05 for in-268
tra group (pre and post) in both groups; this p value269
showed it was significant. ‘Paired t-test’ showed p>270
0.05 for inter groups (compare group-A to group-B);271
this p value showed non-significant results.272
4. Discussion273
The goals of rehabilitation include restoring func-274
tion, pain free full range of motion, and achieving full275
muscle strength and endurance. This paper discusses276
the rehabilitation of CLBP with the application of core277
muscle strengthening special focus on transversus ab-278
dominis and lumbar multifidus muscles.279
The aim of study was to find out the effect of core280
muscle strengthening, lumbar flexibility and gluteus281
maximus strengthening in patients with chronic low282
back pain using pain and function using numerical pain283
rating scale, lumber flexibility, Oswestry Disability In-284
dex, Sorensen test, Gluteus Maximus Strength, Activa-285
tion of transversus abdominis and Modified- Modified286
Schober’sTest, between long duration CLBP and short 287
duration CLBP. The limitation of our study includes 288
very short follow-up, limited sample size and lack of 289
measurement of lateral flexion, extension and rotation 290
ROM of spine. However, patients were included on a 291
very strict inclusion criteria and very objective assess- 292
ment of the outcome parameters. 293
Franca et al. [20] showed the effect of segmental 294
stabilization of core muscle on CLBP pain, which de- 295
creased 99% on visual analogue scale. They explained 296
that the improvement could be due to the fact that this 297
technique addressed two muscles (primary stabilizers) 298
that get affected in low back pain. 299
Hodges [22] and Morris et al. [40] concluded from 300
their study that contraction of TrA develops Intra Ab- 301
dominal Pressure (IAP) within the abdominal cavity 302
by coordinated action of diaphragm, transversusabdo- 303
minis and pelvic floor muscle that serves as a pres- 304
surized balloon attempting to separate the diaphragm 305
and pelvic floor. This creates distraction of the lum- 306
bar spine that decreases the compressive load on it. 307
Liebenson (1996) [39] stated that Multifidus is a pri- 308
mary inter-segmental stabilizer of the spine. It has a 309
short reaction time due to its location near the centre of 310
rotation of the vertebrae. Increased lordosis is a sign of 311
a poor hip extension movement pattern. Decreased ac- 312
tivation of the multifidus, especially Type-2 fibres at- 313
rophy [17,41] has been found in chronic LBP and was 314
improved with stabilization training and restoration of 315
function. 316
Vogt et al. [11] concluded that Gluteus maximus 317
producing stability to the SI Joint is provided by com- 318
pression thus creating a self-bracing mechanism. There 319
is very little movement at the SI joint which is im- 320
portant for the primary function of load transfer from 321
the trunk to legs. If excess movement occurs at the 322
joint, a positional change may occur between the ilium 323
and sacrum thus compromising the L5-S1 interverte- 324
bral joints and disc, SI joint and pubic symphysis could 325
lead to SI joint dysfunction and low back pain. Due to 326
its proximal attachment on to the sacro-tuberous lig- 327
ament, gluteus maximus is thought to cause tighten- 328
ing of the ligament, giving dynamic joint stability and 329
thereby reducing mobility [40]. 330
Asfour et al. [43] supported that the increased 331
strength is associated with biofeedback was a result 332
of both motor unit firing rate and recruitment patterns. 333
Thus after intervention the recruitment order of mus- 334
cles were corrected and the compressive load from 335
spine decreased, consequently producing stabilization 336
of spine which might be the reason for reduced pain 337
and symptoms. 338

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6T. Kumar et al. / Efficacy of core muscle strengthening exercise in chronic low back pain patients
Akuthota et al. [36] concluded that adequate mus-339
cle length and flexibility are necessary for proper joint340
function and efficiency of movement. The restriction341
of mobility thus increases load on the spine [44]. The342
“cat and camel” exercise proves to be a way to achieve343
spinal segmental and pelvic accessory motion [45].344
Rainville et al. [28] concluded that stretching exercises345
can be used to eliminate impaired flexibility and re-346
store normal trunk range of motion. In order to be suc-347
cessful, however, stretching must be performed at the348
patient’s physiological end range and therefore within349
the range of motion that may induce back discomfort.350
The reason for improvement in lumbar flexibility351
could be due to the exercises that were included in this352
study. The cat-camel exercises reduced spinal viscos-353
ity (internal resistance and friction) and floss the nerve354
roots at the outlet of each lumbar level [54], and other355
flexibility exercises were knee to chest, trunk rotation356
in crook lying and side flexion in standing, all these ex-357
ercises created a stretch in the lumbar muscles, which358
could be a reason for improving the flexibility. Connec-359
tive tissue deformation (stretch) occurs to different de-360
grees at different intensities of force. It requires break-361
ing of collagen bonds and realignment of the fibres for362
there to be permanent elongation or increased flexibil-363
ity.364
Healing and adaptive remodelling capabilities allow365
the tissue to respond to repetitive and sustained loads366
if time is allowed between bouts. This is important for367
increasing both flexibility and tensile strength of the368
tissue [55].369
The findings of the present study is in accordance370
with the above stated researches that the increased flex-371
ibility could be due to restoration of mobility which372
was disturbed in chronic low back pain. Thus after373
intervention the mobility of lumbar spine were im-374
proved and the proprioceptive feedback of muscle from375
joint increased, for good balance between flexibility376
and stability. The contraction of transversusabdomi-377
nis is essential for the stabilization of lumbar spine.378
Hodge [22] in his study on efficacy of TrA training sug-379
gested that several points should be considered when380
training this muscle. According to him it is the prin-381
ciple abdominal muscle affected in low back pain and382
should be trained separately from the other trunk mus-383
cles. Hence, in this study activation of Transversus ab-384
dominis was one of the important components for re-385
habilitation of patient with chronic low back pain.386
The findings of the present study is in concordance387
with the above stated researches that the increased ac-388
tivation of TrA could be due to isolated activation of389
TrA by PBU and the co-activation of these with multi- 390
fidus, further increased activation of TrA. Hides et al. 391
(2011) [18] concluded that the ability to contract mul- 392
tifidus was related to the ability to contract TrA with 393
the odds of a good contraction of multifidus being 4.5 394
times higher for patients who had a good contraction of 395
TrA. A poor ability to contract multifidus was related 396
to poor TrA contraction. 397
The reason for improvement could be that Gluteus 398
maximus strengthening exercises incorporated into in- 399
tervention in this study corrected the recruitment or- 400
der [12] and strengthening [27] of gluteus maximus. 401
Kankaanpaa et al. [9] demonstrated increased fatigabil- 402
ity of the gluteus maximus in individuals with CLBP. 403
Leinonen et al. [10] also demonstrated the gluteus 404
maximus to be more easily fatigued in those with non- 405
specific CLBP, but noted improvement in the latency 406
of firing in the gluteus maximus after rehabilitation. 407
Patients who suffer from low back pain often avoid 408
painful movements and subsequently have reduced ac- 409
tivity of gluteus maximus and decreased muscle en- 410
durance through disuse. Low back pain has been as- 411
sociated with changes in the hip extensor recruitment 412
pattern and disturbed lumbo-pelvic rhythm, both to 413
which the gluteus maximus muscle contributes [10, 414
11]. Sakamoto et al. [12] concludedby EMG study that 415
with hip extension and 90 degree knee flexion and hip 416
lateral rotation, the gluteus maximus is recruited max- 417
imally and inhibition of other hip and knee muscles 418
muscle occurs. 419
The result of this study concludes that there was sig- 420
nificant improvement in the gluteus Maximus strength 421
following recruitment and strengthening exercises 422
which was showed objectively by the JHHD and this 423
in effect had a role in improving the patient symptoms. 424
The percentage mean of trunk holding time in this 425
study after intervention was 138.13 sec in group -A and 426
139.07 sec. in group-B. The range of different stud- 427
ies on trunk holding time in non-symptomatic individ- 428
ual is around 77.8 sec to 171.5 sec [50]. The Sorensen 429
test involves all muscle of trunk not only paraspinal 430
(multifidus) but also for hip extensor muscle. Biering- 431
Sorensen [51] reported that a position-holding time 432
less than 176sec predicted low back pain during next 433
year in males, whereas a time greater than 198 sec pre- 434
dicted absence of low back pain. Luoto et al. [50] had 435
shown that a time less than 58 sec was associated with 436
a three times increase in the risk of low back pain, as 437
compared to a time greater than 104 sec. 438
In this study the value of Sorensen test after inter- 439
vention lies in the range in which the chance of LBP 440

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T. Kumar et al. / Efficacy of core muscle strengthening exercise in chronic low back pain patients 7
and its recurrence would be less. It might be due to441
strengthening of multifidusand gluteus maximus [50]442
during the intervention which is an important muscle in443
back endurance. This has been supported by an EMG444
study done by Ng et al. [51] in which they concluded445
that during the Sorensen test, the multifidus demon-446
strates more EMG activity.447
In the first phase of core muscle strengthening ex-448
ercise protocol of the present study multifidus was449
strengthened.450
The improvement in function can be attributed to451
reduction in pain, improvement flexibility of lumbar452
spine, improved back endurance and activation of TrA453
and strength of gluteus maximus. The Correction of re-454
cruitment order of core muscle (primary stabilizer) and455
gluteus maximus by core muscle stabilization, flexi-456
bility and gluteus maximus exercises in both groups.457
With the reduction in pain perception, improvement in458
back endurance and gluteus maximus strength subjects459
noted increased ability to perform their daily activity460
on ODI index which include component like pain in-461
tensity, personal care, lifting, walking, sitting and trav-462
elling. Balance between flexibility and stability of lum-463
bar spine prevent low back pain [53].464
The results of the present study were consistent with465
the study done by Franca et al. [20] who have given466
the effect of segmental stabilization of core muscle on467
CLBP functional disability which decreased to 90%.468
VenuAkuthota et al. [26] study showed decreased pain469
and disability because of improved core stability [24].470
This study showed insignificant results (p0.05)471
in all outcome measure between the group analyses. In472
chronic low back pain the weakness of core muscle (lo-473
cal and global) is not the root cause but the disturbed474
recruitment order of core and gluteus maximus, and475
decrease the flexibility of lumbar spine are the main476
problem. After six weeks of intervention, there might477
be correction in the recruitment order of these mus-478
cles and significant improvement in lumbar mobility.479
Cholewicki et al. [29] small increase in the level of ac-480
tivity of the muscles of the local system could prevent481
spinal instability. The flexibility and endurance also482
depends on the other factors like age, gender, weight,483
lumbar lordosis etc. [50] but it was not analysed in484
present study. The study done by Kumar et al. [56] also485
supported our study which concludes that DMST (dy-486
namic muscular stabilization technique) intervention is487
an effective rehabilitation technique for all CLBP pa-488
tient irrespective of duration (chronicity) of their pain.489
5. Conclusion 490
This study concluded that core muscle strengthening 491
exercise along with lumbar flexibility and gluteus max- 492
imus strengthening is an effective rehabilitation tech- 493
nique for all chronic low back pain patients irrespective 494
of duration (chronicity) of their pain. 495
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