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Background: Exercise is important as adjuvant in the chronic low back pain (CLBP) treatment. Functional training could involve benefits for low back pain (LBP) patients. Objective: To evaluate the effects of a 12-week period of functional resistance training on health-related quality of life (HRQOL), disability, body pain, and physical fitness in CLBP females. Methods: Nineteen females CLBP were recruited according to Paris Task Force on Back Pain criteria. Participants were randomly assigned to an exercise group (EG); and a control group (CG). Subjects were tested at baseline and at week 12 after 24 sessions, 2 days per week. Body pain was assessed using visual analog scale (VAS), disability with Oswestry Disability Index (ODI) and HRQOL with Short Form 36 questionnaire. Physical fitness was measured using: flamingo test, back endurance test, side bridge test, abdominal curl-up tests, and 60-s squat test. Results: EG showed significant improvements in physical function (10%; p< 0.05), body pain (42%; p< 0.05), vitality (31%; p< 0.05), physical component scale (15%; p< 0.05), VAS (62.5%; p< 0.01), ODI (61.3%; p< 0.05), balance (58%; p< 0.05), curl-up (83%; p< 0.01), squat (22%; p< 0.01), static back (67%; p< 0.01), and side bridge (56%; p< 0.01). Conclusion: Periodized functional resistance training decreased pain and disability and improved HRQOL, balance and physical fitness in females with CLBP, and can thus be used safely in this population.
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Journal of Back and Musculoskeletal Rehabilitation -1 (2017) 1–11 1
DOI 10.3233/BMR-169684
IOS Press
Effects of functional resistance training on
fitness and quality of Life in females with
chronic nonspecific low-back pain
Juan M. Cortell-Tormoa,, Pablo Tercedor Sánchezb, Ivan Chulvi-Medranoa, Juan Tortosa-Martíneza,
Carmen Manchado-Lópeza, Salvador Llana-Bellochcand Pedro Pérez-Sorianoc
aDepartment of General and Specific Didactics, Faculty of Education, University of Alicante, Alicante, Spain
bFaculty of Physical Activity and Sports Sciences, University of Granada, Granada, Spain
cFaculty of Physical Education and Sports, University of Valencia, Valencia, Spain
BACKGROUND: Exercise is important as adjuvant in the chronic low back pain (CLBP) treatment. Functional training could
involve benefits for low back pain (LBP) patients.
OBJECTIVE: To evaluate the effects of a 12-week period of functional resistance training on health-related quality of life
(HRQOL), disability, body pain, and physical fitness in CLBP females.
METHODS: Nineteen females CLBP were recruited according to Paris Task Force on Back Pain criteria. Participants were
randomly assigned to an exercise group (EG); and a control group (CG). Subjects were tested at baseline and at week 12 after 24
sessions, 2 days per week. Body pain was assessed using visual analog scale (VAS), disability with Oswestry Disability Index
(ODI) and HRQOL with Short Form 36 questionnaire. Physical fitness was measured using: flamingo test, back endurance test,
side bridge test, abdominal curl-up tests, and 60-s squat test.
RESULTS: EG showed significant improvements in physical function (10%; p < 0.05), body pain (42%; p < 0.05), vitality
(31%; p < 0.05), physical component scale (15%; p < 0.05), VAS (62.5%; p < 0.01), ODI (61.3%; p < 0.05), balance (58%;
p < 0.05), curl-up (83%; p < 0.01), squat (22%; p < 0.01), static back (67%; p < 0.01), and side bridge (56%; p < 0.01).
CONCLUSION: Periodized functional resistance training decreased pain and disability and improved HRQOL, balance and
physical fitness in females with CLBP, and can thus be used safely in this population.
Keywords: Resistance training, disability, therapy, pain, exercise, women
1. Introduction1
Low back pain is related to disability and work ab-2
sence and accounts for high economical costs [1]. In3
the majority of cases of CLBP the etiology is not clear,4
and the term “nonspecific” is thus used [2]. One pos-5
Corresponding author: Juan M. Cortell-Tormo, Department of
General and Specific Didactics, Faculty of Education, University of
Alicante, Campus de Sant Vicent del Raspeig, s/n, 03690, Sant Vi-
cent del Raspeig, Alicante, Spain. Tel.: +34 965909676; Fax: +34
965903721; E-mail:
sible factor in the genesis and persistence of CLBP is 6
mobility, stability and control of the lumbopelvic re- 7
gion [2]. Exercise rehabilitation programs commonly 8
used for patients with CLBP are based on strengthen- 9
ing exercises or trunk stabilization [3]. In one hand, tra- 10
ditional core exercises (TCE) usually include relatively 11
high-intensity exercises that activate both the flexors 12
and extensors of the trunk, superficial muscles of the 13
Global Stabilizing System (GSS) (e.g. back extension 14
or sit up) [4,5]. On the other hand, core stability exer- 15
cises (CSE) aim to activate deep core muscles of the 16
Local Stabilizing Sytem (LSS) (e.g. prone plank, side 17
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2J.M. Cortell-Tormo et al. / Functional resistance training in low-back pain
bridge). Both, TCE and CSE, have been shown effec-18
tive for decreasing pain [6–9] and disability [8–11],19
as well as for improving health-related quality of life20
(HRQOL) [8,12–14]. This could be explained by the21
fact that dysfunction of movement around a joint can22
be a local or a global problem, although both fre-23
quently occur together [4]. A recent systematic review24
reported that exercise contributes to the treatment of25
chronic pain, but highlights that it is still not clear ex-26
actly which factors or particular types of exercises may27
be attributed to such improvements [15].28
Efficient movement function and the maintenance of29
balance during dynamic tasks are more complex than30
merely adequate force production from the muscles. It31
requires sensory, biomechanical and motor-processing32
strategies along with learned responses from previous33
experience and anticipation of change [16]. Spinal pro-34
prioception and balance have been found to be abnor-35
mal in patients with chronic low back pain [17,18].36
In parallel, Trunk balance deficits and muscle impair-37
ments could also originate from poor position sense,38
which has been reported to be present in individuals39
with CLBP [19].40
Exerting external forces while attempting to main-41
tain dynamic balance forms the base of success for per-42
forming efficiently and safely activities of daily liv-43
ing [20]. Patients with CLBP have difficulty main-44
taining balance, especially under challenging condi-45
tions [21]. Stabilization of the trunk is crucial for main-46
taining static or dynamic balance, especially to provide47
a solid base when attempting to exert forces upon ex-48
ternal objects [20]. Patients with chronic low back pain49
have poorer postural control of the lumbar spine than50
healthy control subjects and this difference increases51
with increasing task difficulty level [22]. Thus, the goal52
of core stability exercise programs is enabling perfor-53
mance of high-level activities in daily life and sports,54
while keeping the spine stabilized [23].55
TCE and CSE involve a limited motor challenge.56
These exercises should be used in the early stages of57
intervention in CLBP patients, but if the aim is to make58
more functional exercises that involve a continuum in59
the motor problem, we must train specific movements60
with asymmetrical loads, involving multiple joints and61
planes of motion at the same time (multi-joint and mul-62
tiplanar) that correspond more closely to how humans63
interact with their environment [24].64
Functional Resistance Training (FRT) involves mul-65
tiplanar and multijoint resistance exercises that simu-66
late movement patterns from everyday life and sport.67
Functional training exercises tend to focus more on the68
coordination, technique, posture, and core engagement 69
instead of on training loads. The goal of FRT is not hy- 70
pertrophy but to promote a potential motor problem in 71
order to train dynamic stabilization. Appropriate func- 72
tional exercises are those in which the lumbo-pelvic 73
region remains aligned within the neutral zone by co- 74
contraction of the muscles of the trunk, while other 75
demands executed with the extremities are simultane- 76
ously and successfully fulfilled [25]. This method of 77
training usually includes: a) spinal stabilization exer- 78
cises; b) balance and proprioceptive exercises; c) flex- 79
ibility exercises; d) resistance training exercises [26]. 80
Motor improvements obtained by functional training 81
have been attributed to the mechanical principle of 82
specificity [27]. 83
Poor movement patterns can lead to back disor- 84
ders [28]. Control of quality of movement patterns in 85
FRT is more challenging than in other types of exer- 86
cise, and could thus represent a good strategy for treat- 87
ing CLBP. However, the effects of FRT in subjects with 88
CLBP are not currently known. Therefore, the aim of 89
the present study was to evaluate the effects of func- 90
tional resistance training on HRQOL, pain, disability 91
and physical fitness related to daily activities in women 92
with CLBP. 93
2. Methods 94
2.1. Subjects 95
Twenty-four women from an Outpatient Physiother- 96
apy Clinic in Spain volunteered to participate in this 97
study. During the selection procedure, a physician re- 98
viewed their medical records and clinical status and 99
confirmed the diagnosis according to Paris Task Force 100
on Back Pain criteria [29]. Subjects received an orien- 101
tation to study procedures and were informed of the ex- 102
perimental risks. All subjects signed an informed con- 103
sent document before the investigation. The investiga- 104
tion was approved by the University of Alicante Re- 105
search Ethics Board for the Use of Human Subjects. 106
The inclusion criteria were: 1-women between 20 and 107
55 years of age; 2-women with low back pain as a pri- 108
mary complaint, without associated leg pain; 3-women 109
suffering from chronic (>3 months, >3 d·wk1) non- 110
specific (soft tissue in origin) low-back (lumbar 5 to 111
lumbar 1) pain; and 4-no history of formal exercise 112
training. Subjects were excluded if they: 1-were receiv- 113
ing concurrent treatments from another practitioner for 114
their low back pain; 2-were diagnosed as having a tu- 115
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J.M. Cortell-Tormo et al. / Functional resistance training in low-back pain 3
Table 1
Characteristics of females with low-back pain at baseline
Exercise Control
group group
(N=11) (N=8) P
Age (yr) 35.6 ±7.9 35.6 ±9.7 0.934
Duration of symptoms 19 ±6.3 20.4 ±5.6 0.628
Weight (kg) 61.3 ±9.9 65.4 ±5.8 0.302
Height (cm) 163.2 ±8.9 164.2 ±5.9 0.200
Body mass index 23.8 ±2.3 24.3 ±2.4 0.619
Waist-hip ratio 0.7 ±0.04 0.7 ±0.05 1.000
Muscular mass (kg) 20.7 ±2.7 21.9 ±1.7 0.137
Fat mass (kg) 22.6 ±3.3 24.5 ±3 0.248
Values expressed as mean ±standard deviation.
mor, infection, or inflammatory disease affecting the116
spine; 3-had spinal or lower-limb surgery; 4-had spinal117
fractures or structural deformities such as spondy-118
lolisthesis and spondylolysis; 5-had any contraindi-119
cations to exercise therapy (e.g., uncontrolled hyper-120
tension, previous myocardial infarction, cerebrovas-121
cular disease, peripheral vascular disease, respiratory122
disorders); 6-were involved in workers’ compensation123
claims; 7-had signs of nerve root compromise, defined124
as decreased tendon reflexes, sensory loss, and motor125
deficits; and 8-were receiving medications other than126
analgesics and nonsteroidal anti-inflammatory drugs.127
The subjects were randomly assigned to either an ex-128
ercise group (EG) or a control group (CG) using a ran-129
domized number sheet. The EG and CG presented sim-130
ilar characteristics at baseline (Table 1).131
Initially, 24 subjects took part in the study and 19132
completed the 12-week follow-up (EG n=11; CG133
n=8) (Fig. 1).134
Each subject performed all the tests and question-135
naires in two sessions and the sequence of application136
was the same at baseline and after 12 weeks. First, the137
diagnosis of CLBP was verified, then the HRQOL, the138
visual analog scale (VAS) and the Oswestry Disability139
Index (ODI) were administrated. The second day, the140
fitness test battery was applied.141
2.2. Procedures142
Subjects completed health surveys at baseline and143
week 12. These included the visual analog scale (VAS)144
for the degree of back pain felt by the subject during a145
typical week, the Oswestry Disability Index (ODI), and146
the Short-Form 36 Health Survey (SF-36). The VAS147
is a simple visual scale used to measure pain intensity148
(0 =no pain; 10 =maximal pain) [30]. The ODI is149
a disease-specific outcome measure used in the man-150
agement of spinal disorders (0 =no disability; 100 151
=maximum disability) [31]. The Spanish version of 152
the SF-36 [32] was used to evaluate HRQOL. The SF- 153
36 assesses eight dimensions: physical function, role 154
physical problems, body pain, general health percep- 155
tion, vitality, social function, role emotional problems, 156
and mental health. The scale of each dimension runs 157
from ‘0 =very poor’ to ‘100 =very good’. 158
2.3. Anthropometric measures 159
To evaluate height (cm) a stadiometer (SECA, model 160
225, Germany) with a range scale of 0.10 cm was used 161
and body mass (kg) was measured to the nearest 0.1 kg 162
using a digital scale (Philips, type HF 351/00). These 163
parameters were assessed prior to any physical perfor- 164
mance test. Body mass index (kg·m2) was calculated. 165
Waist-Hip ratio (WHR) was consequently calculated 166
as the ratio of waist circumference over the hip cir- 167
cumference. The anthropometric measures taken were 168
8 skinfolds by the same investigator (ISAK). Muscle 169
mass was calculated using the Lee equation [33]. Fat 170
mass was calculated using the Withers equation [34]. 171
2.4. Physical fitness 172
First, postural balance was assessed with a blind 173
flamingo test [44], in which the barefoot subject stood 174
on one leg while the other leg was flexed at the knee 175
and the ankle was held by the hand of the same side 176
of the body, performed with closed eyes. The number 177
of trials that the subject needed to complete 30 s of 178
the static position was measured. The outcome was ex- 179
pressed as the number of trials (equal to the number of 180
falls +1). The test-retest intraobserver reliability coef- 181
ficient was r=0.92. 182
Then, the static back endurance test (intraclass co- 183
efficient =0.88) was performed with the subject ly- 184
ing prone on a flat bench, with the ankles anchored un- 185
derneath a pad. The tip of the iliac crest rested on the 186
edge of the bench and the arms were folded across the 187
chest. Once the subject was lying down with a hori- 188
zontal position, the stopwatch was started. When the 189
subject was no longer able to maintain the starting po- 190
sition, the watch was stopped. For the side bridge test 191
(intraclass coefficient =0.90), the subject was asked 192
to determine the preferred side for the test. This was in 193
accordance with previous studies where subjects were 194
able to self-select which side would be measured [35]. 195
The starting position involved the subject lying side- 196
ways on the floor while propped up on the feet and the 197
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4J.M. Cortell-Tormo et al. / Functional resistance training in low-back pain
Fig. 1. Diagram of the study, total number of subjects and number of dropouts.
forearm closest to the ground. The legs were extended.198
The subject lifted the body up off the floor and held199
this position for as long as possible while supporting200
the body weight. The stopwatch was started when the201
subject assumed the correct position and was stopped202
when it was no longer maintained [36].203
Immediately afterward, the abdominal curl-up tests204
measured the muscular endurance of the abdominal205
muscles (intraclass coefficient =0.87). The test was206
terminated when the subject was unable to maintain the207
required cadence or unable to maintain the proper curl-208
up technique for 2 consecutive repetitions despite re-209
ceiving feedback from the researcher. A maximum of210
3 corrections were allowed by the evaluator before ter-211
mination of the test. The subject was positioned supine212
with the head resting on the mat, arms straight at sides213
and parallel to the trunk, palms of hands in contact with214
the mat, and the middle finger tip of both hands at the215
0 mark (identified by a piece of tape). Knees were bent216
at 90and the heels kept contact with the mat. The test217
was performed with shoes on and cadence was set by a218
metronome (50 bpm). The test started with a slow curl-219
ing up of the upper spine far enough so that the middle 220
finger tips of both hands reached the 8-cm mark iden- 221
tified by tape. Each subject completed as many repeti- 222
tions as possible. 223
Finally, the 60-s squat test (intraclass coefficient =224
0.81) was chosen as a measure of lower body muscle 225
endurance. It was performed third, and for the greatest 226
possible number of repetitions in 1 min with a thigh 227
position parallel to the floor at the bottom of the range 228
of movement and without carrying out assisted move- 229
ments using other body segments [37]. 230
To assess test-retest reliability, intraclass correla- 231
tions (ICCs) comparing baseline with week 12 were 232
performed using the CG data. The following dependent 233
variables were analyzed: postural balance, abdominal 234
crunch, 60-s squat, static back, side bridge, PCS, and 235
MCS. 236
2.5. Exercise therapy 237
The EG exercised in Physiotherapy Clinic, two 238
times per week for a 12-week period. The EG was di- 239
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J.M. Cortell-Tormo et al. / Functional resistance training in low-back pain 5
Stage 1 Exercises
The aim of the first stage is to train the specific isometric co-contraction of
transversus abdominis with lumbar multifidus at low levels of maximal voluntary
contraction and with controlled respiration, in weight bearing within a neutral
lordosis [52].
4-point kneeling and lying positions Lying (controlled
leg movement). Lying on back. Sitting and standing
Stage 2 Exercises
The second phase is the associative stage, where the focus is on refining a par-
ticular movement pattern in analytic and isometric resistance training.
Abdominal crunch. Back extension. Side plank. El-
bow bridge. Squat. Lunges. Seat pull and row.
Stage 3
The third stage is the aim of the specific exercise intervention, whereby sub-
jects can dynamically stabilize their spines appropriately during exercises like a
functional demands of daily living.
Single leg Deadlift. Anterior Reach. Lunges. Stand
row. Pull squat. Stand push.
Applications Exercises
Single leg Deadlift Anterior Reach
Lunges Stand row
Pull squat Stand push
Fig. 2. Exercise program.
vided in three subgroups (two groups of 4 and one of240
3 subjects). Each subgroup was monitored by the same241
specialist (qualified personnel), who led each train-242
ing session. At least one trained monitor was always243
present to verify the correct application of the method-244
ology. Each therapy session ranged from 45 to 60 min245
depending on the phase. A warm-up of 6–7 min of246
mild cardiovascular exercise followed by 3–4 min of247
stretching was always performed prior to the training248
sessions. A cool-down of 1 min of mild cardiovascular249
exercise followed by 4 min of stretching was always250
performed after the training sessions.251
The subjects were instructed in the different exer-252
cise techniques and in controlling exercise intensity253
through the combined use of a targeted number of rep-254
etitions and perception of effort during two sessions255
before beginning the training program. The criteria of256
body position, ranges of motion and movement speed257
followed the guidelines described by O’Sullivan [38],258
Koumantakis et al. [39]; Carter et al. [36], McGill [40];259
and Santana [41].260
The load (resistance) for each exercise was deter- 261
mined according to the rating of perceived exertion 262
in active muscles by using the OMNI resistance ex- 263
ercise scale for active muscles. The maximum value 264
(10-extremely hard) indicates that the subject has per- 265
ceived that the set performed with a previously deter- 266
mined number of repetitions has been performed with a 267
maximal volitional effort, while the 0 value (extremely 268
easy) indicates no effort at all [42]. This enabled the 269
establishment of new loads for each exercise to contin- 270
ually stress the bodies of the EG throughout the study. 271
The load was readjusted when the subject was unable 272
to maintain the required intensity or unable to main- 273
tain the proper technique (co-contraction while main- 274
taining a neutral lordosis) for 2 consecutive repetitions 275
despite feedback from the researcher. 276
The stabilizing exercises were taught by asking the 277
patients to draw in the stomach while giving them 278
verbal, visual, and tactile feedback and measuring 279
the pressure change with a biofeedback meter [10]. 280
The control of neutral lordosis for seat pull and row 281
exercises was determined with the pressure changes 282
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6J.M. Cortell-Tormo et al. / Functional resistance training in low-back pain
Fig. 3. Periodization of training.
on biofeedback meter. The EG performed upper- and283
lower-body resistance training exercises that consisted284
of free weights (dumbbell), gym apparatus and body285
weight (Fig. 2).286
The resistance machine used was the Life Fitness287
Dual Adjustable Pulley (Life FitnessTM), which al-288
lowed for full range of motion, smooth action, and easy289
pin adjustment of the load. From seventeen to twenty290
sessions symmetric and asymmetric loads were com-291
bined. First set symmetric, second and third asymmet-292
ric (changing high load for side). The last five ses-293
sions in stand row and stand push exercises asymmet-294
ric loads were applied. In each set, half of repetitions295
were performed with a higher load in the non-dominant296
hand (from the 20th to the 24th sessions, the differ-297
ence between the loads progressed from 10 to 30%)298
and the other half with a higher load in the dominant299
hand. During the entire 12-wk period, participants in300
the CG continued their daily activities, which did not301
include any form of physical exercise similar to those302
in the therapy. The number of sets, repetitions, resting303
period between sets and exercises and the desired per-304
ception of effort for the sets were the same for three 305
subgroups during the 12 weeks of training (Fig. 3). 306
2.6. Statistical analysis 307
All values are reported as mean ±SD. Age, height, 308
body mass, body fat, abdominal curl-up, 60-s squat, 309
side bridge, static back endurance, postural balance, 310
VAS, ODI, and SF-36 PCS and MCS were analyzed 311
via a general linear model with repeated-measures 312
analysis of variance (ANOVA), to compare the CG and 313
EG groups from baseline to week 12. Data distribu- 314
tion was checked by the Shapiro-Wilk test. For nor- 315
mally distributed variables, the Levene test for homo- 316
geneity of variances was completed on each dependent 317
variable during the ANOVA. When the data were not 318
normally distributed, the Friedman ANOVA followed 319
by the Wilcoxon signed-rank test was used. When a 320
significant F ratio was achieved, post hoc comparisons 321
were completed using a Fisher least significant differ- 322
ence. For all tests, the significance level was set at p323
<0.05. The corrected effect size was estimated with 324
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J.M. Cortell-Tormo et al. / Functional resistance training in low-back pain 7
Table 2
Health-related quality of life at baseline and after 12-wk of training (exercise group, N=11; control group, N=8)
Baseline Week 12
Exercise Control Exercise Control Training effect
M±SD M ±SD M ±SD M ±SD M (95% CI) ES P
VAS (0–10) 4 ±1.8 4.5 ±1.6 1.5 ±1.5 4.4 ±1.4 2.5 (3.9 to 1.1) 1.45 0.001
ODI (0–100) 15.5 ±8.4 14 ±12 6 ±6.1 14.5 ±11.1 9.5 (17.5 to 1.4) 1.24 0.023
SF-36 (0–100)
Physical function 83.2 ±12.1 86.3 ±12.5 91.8 ±6.4 84.4 ±9 8.6 (17.5 to 0.2) 0.85 0.048
Role physical 63.6 ±43.8 71.9 ±41.1 86.4 ±25.9 75 ±40 22.7 (55.6 to 10.2) 0.60 0.169
Body pain 52.8 ±27.3 53.2 ±10.1 75.1 ±24.9 65.5 ±22.4 21.9 (40.7 to 3.1) 0.82 0.024
General health 63.9 ±13.5 66.5 ±30.9 73.4 ±13.9 65.9 ±30.7 9.5 (28.9 to 10) 0.66 0.329*
Vitality 52.7 ±13.7 54.4 ±17.2 68.9 ±16.3 71.9 ±13.9 15.5 (28.7 to 2.2) 1.03 0.024
Social function 70.5 ±28.7 70.3 ±32.7 89.8 ±13.5 87.5 ±17.7 19.3 (40.2 to 1.5) 0.82 0.068
Role emotional 69.7 ±43.3 70.8 ±37.5 69.7 ±45.8 75 ±46.3 0 (37.8 to 37.8) 0.00 1.000*
Mental health 62.5 ±15.5 66.5 ±22.1 73.5 ±14.9 72.5 ±17.9 10.9 (26 to 4.1) 0.82 0.151*
Component scale (SF-36) 0.00
Physical component scale 46.4 ±7.7 47.5 ±9.4 53.2 ±6.8 48.4 ±7.3 6.9 (13.6 to 0.2) 0.82 0.045
Mental component scale 42.5 ±13.9 43.2 ±11.4 46.2 ±11.8 48.8 ±10.6 3.7 (14.2 to 6.9) 0.00 0.483*
Values expressed as mean (M) ±SD, 95% CI and Effect Size (ES). VAS, Visual Analog Scale. ODI, Oswestry Disability Index. SF-36, Short
Form 36 Health Survey Pvalues of analysis of variance for repeated measures from baseline to week 12. *Non-parametric statistics.
Table 3
Physical fitness outcomes at baseline and after 12 weeks of physical training (exercise group, N=11; control group, N=8)
Baseline Change to 12 Weeks
Exercise Control Exercise Control Training effect
M±SD M ±SD M ±SD M ±SD M (95% CI) ES P
Balance (trials to 60 s) 8 ±5.8 11.8 ±9.9 3.4 ±3 11.1 ±9.3 7.8 (14.5 to 1.1) 0.95 0.024*
Curl-up (rep) 32.5 ±16.8 33.8 ±26.4 59.5 ±16.4 33.5 ±28.1 27 (45.8 to 8.3) 1.56 0.006*
Squat (rep) 39.5 ±9.5 39.1 ±6.1 48.2 ±1.7 35 ±15.6 13.2 (22.3 to 4) 1.22 0.006
Static back (s) 81.6 ±23.6 66.7 ±26.7 136 ±38.9 70.1 ±31.9 65.9 (95.3 to 36.6) 1.62 0.000
Side bridge (s) 47.4 ±29.8 35.1 ±20.9 74.1 ±27.8 27.7 ±20.4 46.4 (70.7 to 22.1) 0.89 0.000
Values expressed as mean (M) ±SD and the training effect 95% CI. Effect Size (ES). Pvalues of analysis of variance comparing differences
between groups at week 12; rep =number of repetitions performed; s =seconds. * Non-parametric statistics.
Hedges’ g[43]. The following scale was used to cate-325
gorize the magnitude of effect: <0.2 =trivial; 0.2–0.5326
=small; 0.5–0.8 =medium; 0.8–1.3 =large, and >327
1.3 =very large. All variables are reported as mean ±328
Standard Deviation (SD).329
3. Results330
Attendance to the therapy was controlled for every331
session. Only one participant from the EG dropped out332
because she changed her work place. Eleven patients333
in the EG attended more than 95% of the sessions, and334
8 patients in the CG fully completed the measurement335
protocol. Their results were included in the analysis.336
3.1. HRQOL, VAS, and ODI337
Baseline values showed no differences between the338
groups in any of the questionnaires (Table 2). After 339
12 weeks of exercise, a significant improvement at- 340
tributable to the treatment effects was found in physical 341
function (10%), body pain (42%), vitality (31%), phys- 342
ical component scale (15%), VAS (62.5%), and ODI 343
(61.3%), all in favor of EG. 344
3.2. Physical fitness 345
At baseline values in the physical tests for the EG 346
and the CG, no differences were observed (Table 3). 347
The EG showed significant improvements in balance 348
(58%), curl-up (83%), squat (22%), static back (67%), 349
and side bridge (56%) when compared with the CG/EG 350
at baseline (Table 3). 351
Figure 4 shows HRQOL at baseline (panel A) and 352
after 12 weeks of training (panel B) in comparison to 353
Spanish asymptomatic population [45]. 354
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8J.M. Cortell-Tormo et al. / Functional resistance training in low-back pain
CG =Control group. EG =Exercise group. RPOP =Reference popula-
tion [32]. PF =Physical function. RP =Role physical. BP =Body Pain. GH
=General health. V =vitality. SF =Social function. RE =Role emotional.
MH =Mental health. PCS =Physical component summary. MCS =Mental
component summary.
Fig. 4. Health-related quality of life at baseline (A) and after 12-wk
of training (B) in comparison to Spanish asymptomatic population.
4. Discussion355
This study sought to determine the effectiveness356
of functional resistance training as a rehabilitation357
strategy for individuals with CLBP. The methodology358
(1 and 2 stages) of the present study has been estab-359
lished to be suitable for studies which aim to detect360
changes in outcome measures of low back pain [38].361
The main contribution offered by this study is the in-362
clusion of a final stage which represents an increase in363
work intensity for the core area and in motor complex-364
ity for movement control. This is achieved from limit-365
ing the base of support, movement and asymmetries in366
the load.367
The present data support that the exercise pro-368
gram used is effective at inducing significant changes369
in physical fitness. The development of the muscu-370
loskeletal system produced by functional resistance371
training reduced pain and disability, recovering HRQOL
as well. Large improvements in muscular strength and373
balance were also reported within the EG. The baseline 374
values of the VAS, the ODI, and HRQOL were very 375
low among subjects in the present study. In the VAS, 376
a decrease of approximately two points (30%) has 377
been considered to be clinically important [46]. In the 378
present study, the change in VAS from baseline in the 379
EG was 62.5%. The improvement in pain symptoms 380
is somewhat higher than those obtained in other stud- 381
ies whose initial values were similar [47] or higher [7]. 382
Also improvement in pain symptoms is higher in sub- 383
jects who had higher initial values [48,49]. The find- 384
ings of the ODI were clinically important. The percent- 385
age decrease in the exercise group was 61.3%. These 386
results are consistent with other studies [9,50,51]. Be- 387
fore intervention, the subjects showed lower values in 388
HRQOL than reference values for the general Span- 389
ish population [45]. After 12 weeks of training, the ex- 390
perimental group showed FF, RF, SG, V, FS, SM and 391
PCS very similar to the reference population. In the DC 392
scale, there is also a marked improvement although it 393
does not match with the reference population. HRQOL 394
showed improvements similar to other studies [8]. 395
Previous CLBP exercise rehabilitation programs 396
used analytic exercises with low-moderate symmetric 397
loads focused on the core area [10,11,51,52] or high 398
loads [50] and whole-body workout [8]. Daily living 399
activities, either recreational or professional, could be 400
represented by global movements with limited stabil- 401
ity, asymmetric and with moderate-heavy load. Func- 402
tional training movements might be better for the de- 403
velopment of core strength and power due to the force, 404
velocity, and core stabilizing requirements that are 405
similar to the demands of daily living skills. People 406
with CLBP present motor control problems and/or de- 407
ficiencies that affect the ability to activate the muscles 408
responsible for stabilizing the spine [53]. Our study fo- 409
cused on progressively increasing the complexity and 410
intensity of the core area stability including exercises 411
of most muscle groups of the musculoskeletal system. 412
The aim of the first stage of this study was to train 413
the specific isometric co-contraction of transversus ab- 414
dominis with lumbar multifidus at low levels of maxi- 415
mal voluntary contraction and with controlled respira- 416
tion, in weight bearing within a neutral lordosis, main- 417
taining neutral zone. In the second stage, this was car- 418
ried out while maintaining the spine in a neutral lor- 419
dotic position and finally with normal spinal move- 420
ment. Segmental control and pain control must be 421
ensured at all times. This can be performed for sit 422
to stand, walking, lifting, bending, twisting, extend- 423
ing, etc. Subjects were encouraged to carry out regu- 424
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J.M. Cortell-Tormo et al. / Functional resistance training in low-back pain 9
lar resistance exercises while maintaining correct pos-425
tural alignment, low level local muscle system co-426
contraction and controlled respiration.427
Previous CLBP exercise rehabilitation programs428
have used a motor learning model in which the third429
stage subjects can dynamically stabilize their spines430
appropriately in an automatic manner during the func-431
tional demands of daily living [38]. However, these432
works did not apply controlled overload when subjects433
made the movements. This might be a potential error434
in the rehabilitation of CLBP because the movements435
can change after applying loads, which is important be-436
cause activities of daily living can be performed un-437
der external loads. The rationale for a global and asym-438
metric exercise regime was to mimic programs used by439
athletes that train specific skills, usually during a last440
phase of training. The same problem can be seen in441
several exercise rehabilitation programs [11,51,52]. In442
fact, most of them include, besides the therapy through443
exercises, educational and/or training therapies on pos-444
tural hygiene and ergonomics to improve motor skills445
and prevent relapse [10,51].446
In conclusion, many studies have examined the use447
of progressive overload exercise as a rehabilitative tool448
and have found mixed results. To date, most of the449
training programs have focused on analytic exercises450
and have used body weight and/or machine devices to451
add external resistance. Here, we used a functional re-452
sistance training program in females with CLBP and453
we have reported significant improvements in mus-454
cular strength and balance. The improvements in the455
musculoskeletal system were translated into reduced456
pain, disability and improved HRQOL. The data sug-457
gest 3 important points for rehabilitating CLBP: 1) the458
effectiveness of using a progressive functional resis-459
tance training program, 2) the relevance of including460
in the exercise program both symmetric and asymmet-461
ric loads, and 3) the need for controlling the quality462
of the movement during each exercise. Future research463
should focus on functional resistance training as a form464
of CLBP rehabilitation, its effects on different popu-465
lations (men or women with higher rates of disability466
and pain, different age groups) and the time-course ef-467
fects of this training regime and detraining. There is468
also a need for studies comparing the effects of FRT469
with other exercise methods.470
The present study also included some limitations.471
There was a lack of practitioner and participant blind-472
ing, although our results are consistent with the litera-473
ture. The sample size of the study does not allow for474
generalization of the results. The reason for this rela-475
tively small sample was the need for constant control 476
and feedback about the quality of movement during all 477
exercises of the intervention. Finally, the conclusions 478
of this study must be taken with caution when consid- 479
ering patients with different age, gender, and previous 480
physical activity level or background symptoms. 481
Acknowledgments 482
The authors wished to thank the Fisioterapia Lledó 483
by the logistical support. This study was supported by 484
grant: DEP2011-30009-C02-01 from the Spanish Min- 485
istry of Economy and Competitiveness. 486
Conflict of interest 487
None to report. 488
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... The electronic search retrieved 14,389 documents, of which 12,793 were excluded as duplicates, 1464 were excluded after screening by title and abstract, and 18 were excluded after full-text reading. Therefore, 17 studies [35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] were included in the qualitative synthesis after applying the eligibility criteria. Of these, six were included in the meta-analysis 35,37,41,46,48,51 . ...
... Therefore, 17 studies [35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] were included in the qualitative synthesis after applying the eligibility criteria. Of these, six were included in the meta-analysis 35,37,41,46,48,51 . Figure 1 shows the search phases and screening of the studies included in the qualitative (systematic review) and quantitative (meta-analysis) synthesis. ...
Full-text available
Exercise interventions have been recommended for people with non-specific low back pain. The literature is scarce regarding the effects of exercise on muscle strength, endurance, and electrical activity of lumbar extensor muscles. Electronic searches were carried out from May 2020 until August 2020 in the following databases: PUBMED, CENTRAL, EMBASE, PEDro, SPORTDiscus, Scielo, and LILACS. Only randomized controlled trials with passive and active control groups were included. The methodological quality of the included studies was performed using the Physiotherapy Evidence Database Scale. Eight studies, involving 508 participants, were included in metanalytical procedures. Exercise interventions demonstrated superior effects on muscle activity (Electromyography) when compared with active controls (p < 0.0001). Exercise interventions demonstrated superior effects on muscle endurance (Sorensen Test) when compared with passive (p = 0.0340) and active controls (p = 0.0276). Exercise interventions demonstrated superior effects on muscle strength (Machine) when compared with passive controls (p = 0.0092). Exercise interventions can improve muscle strength, endurance, and electrical activity in people with non-specific low back pain.
... Functional resistance training was used by Cortell-Tormo et al. [44] in a randomized controlled trial among 24 female subjects affected by non-specific LBP to evaluate its effects on pain (VAS), disability (ODI), health-related quality of life (Short Form 36 Health Survey-SF-36) and physical fitness. The authors also applied exercises similar to ours (e.g., segmental stabilization, lunges and squats) in a progressive manner, as well as similar physical examination methods (e.g., static trunk extensor endurance, side plank, and timed abdominal curl tests) being used. ...
... The authors also applied exercises similar to ours (e.g., segmental stabilization, lunges and squats) in a progressive manner, as well as similar physical examination methods (e.g., static trunk extensor endurance, side plank, and timed abdominal curl tests) being used. Although the number of subjects was smaller and their intervention was shorter (12 weeks; two sessions weekly for 45-60 min) than ours, significant improvements were observed in the target group in all the measured variables compared to the control group except in the results related to the SF-36 [44]. Despite the methodological differences in the respective pieces of research, it can be concluded that functional exercises are a fundamental part of both preventive and therapeutic interventions in LBP or other musculoskeletal diseases. ...
Full-text available
According to the latest data published by the WHO, 1.71 billion people suffer from musculoskeletal disorders and 568 million are affected by back pain, making these the most significant occupational health problems. The aim of this study was to analyze the effects of a newly developed Multimodal Workplace Training Program implemented among young sedentary employees in order to treat and prevent these problems. The 20-week Training Program was conducted at the National Instruments Corporations’ Hungarian subsidiary in Debrecen between January and June, 2019. Pre- and post-intervention questionnaires were used to assess subjective parameters. Baseline and follow-up physical examinations were performed using the SpinalMouse, Y-Balance, Sit and Reach, Prone and Side Plank, Timed Abdominal Curl, and Biering-Sorensen tests. The results for 76 subjects were eligible for statistical analysis. Our Training Program was effective in several aspects, including a reduction in musculoskeletal symptoms and improvements in posture (p < 0.001), in dynamic (p < 0.01) and static-isometric (p < 0.001) core strength, in flexibility (p < 0.001), in spinal inclination in the sagittal (p < 0.001) and frontal (p < 0.01) plane, and in balance and coordination (p < 0.05). The Multimodal Progressive Functional–Proprioceptive Training was highly effective, and the application of such a complex training program can be recommended in workplace settings.
... After the intervention, there was a reduction in functional disability in RG and RCG. The results of functional lumbar disability in the present study agree with the findings of a study by Cortell-Tormo [43], which analyzed the effects of 12 weeks of functional resistance training in women with LBP. The authors found a reduction in pain and disability, and an increase in health-related quality of life, balance, and physical fitness. ...
Aim: To analyze the effects of two training programs on health variables in adults with low back pain (LBP). Methods: Thirty-eight adults were randomly divided into three groups: resistance training (RG); resistance training with core training (RCG) and control (CG). Results: There were reductions in body mass index (BMI) in RG and RCG, waist circumference in RG and RCG, pain in RG, RCG and CG, CK in RCG, stress in RG and RCG, functional deficiency in RG and RCG and increases in trunk flexor and extensor strength in the RG and RCG. Conclusion: Resistance training, with or without core training exercises, reduced the levels of LBP, functional disability, stress and CK, and increased the strength of trunk flexors and extensors. Trial registration: Brazilian Clinical Trials Registry: ReBEC (RBR-5khzxz)
... disminuyó sustancialmente. Estos resultados están en consonancia con diversos estudios, donde disminuyen o eliminan el dolor lumbar (Ciolac & Rodrigues-da-Silva, 2016;Cortell-Tormo et al., 2018) después de un programa de entrenamiento de fuerza. En la revisión de Tanaka, Ozawa, Kito, & Moriyama (2013) se concluyó que tanto el entrenamiento de fuerza como el aeróbico eran efectivos para redu- cir el dolor de rodilla en personas con osteoartritis. ...
Full-text available
La sociedad está envejeciendo, y se estima que este segmento seguirá aumentando en los próximos años. Objetivo: Examinar los efectos que producen 5 semanas de entrenamiento en el rendimiento funcional, fuerza de agarre, perímetro de cintura, masa grasa y percepción de dolor general. Método: 28 sujetos (edad ≥ 55 años), sedentarios, participaron en un programa de entrenamiento de fuerza y entrenamiento aeróbico, de 5 semanas, 5 sesiones semanales de 50-60 minutos de duración. Resultados: Existen diferencias estadísticamente significativas entre los valores previos y posteriores al programa. La magnitud de estas diferencias puede considerarse grande en el Timed Up and Go Test (-27.3%, p=0.000, d=3.01), 30-Second Chair Stand Test (+42%, p=0.000, d=1.77) y percepción de dolor día (-54.7%, p=0.000, d=1.27) y noche (-58.2%, p=0.000, d=1.02). Conclusión: Tras la aplicación del programa de entrenamiento concurrente descrito, todas las variables analizadas han evolucionado favorablemente. Dichas variables están directamente relacionadas con la composición corporal, calidad de vida, reducción del dolor, así como mejora de fuerza para las actividades cotidianas de las personas mayores.
Objective: To determine which type of exercise is best for reducing pain and disability in adults with chronic low back pain (LBP). Design: Systematic review with network meta-analysis (NMA) of randomised controlled trials (RCTs). Literature search: Six electronic databases were systematically searched from inception to July 2021. Study selection criteria: RCTs testing the effects of exercise on reducing self-perceived pain or disability in adults (18-65 years) with chronic LBP. Data synthesis: We followed the PRISMA-NMA statement when reporting our NMA. A frequentist NMA was conducted. The probability of each intervention being the most effective was conducted according to SUCRA values. Results: We included 118 trials (9710 participants). There were 28 head-to-head comparisons, 7 indirect comparisons for pain, and 8 indirect comparisons for disability. Compared with control, all types of physical exercises were effective for improving pain and disability, except for stretching exercises (for reducing pain) and McKenzie method (for reducing disability). The most effective interventions for reducing pain were: Pilates, mind-body and core-based exercises. The most effective interventions for reducing disability were: Pilates, strength and core-based exercises. On SUCRA analysis, Pilates had the highest likelihood for reducing pain (93%) and disability (98%). Conclusion: Although most exercise interventions had benefits for managing pain and disability in chronic LBP, the most beneficial programmes were those that included: (i) at least 1-2 sessions/week of Pilates or strength exercises; (ii) sessions of <60 min of core-based, strength or mind-body exercises; and, (iii) training programs from 3 to 9 weeks of Pilates and core-based exercises.
Low back pain is a major health problem resulting in psychosocial and physical disability. The prevalence of LBP and risk of recurrence is rising due to the sedentary life style, poor postural awareness and short term oriented intervention plans. It is the need of the time to design one or more exercise plans that can improve pain and functional disability and prevent recurrence of symptoms in patients with mechanical low back pain. Objective: The objective of this study is to compare the effects of core stability exercises and endurance training on the pain and functional disability in the population having mechanical low back pain. Materials and Methods: It was a quasi-experimental study with 74 patients with chronic low back pain, divided equally in two groups containing 37 patients each. Both groups were treated with baseline of moist heat pack in combination with interferential. Group A was treated with core stability exercises and group B was treated with endurance training for five times a week. Pre and post treatment scores were compared with NPRS for intensity of pain and Oswestry Disability Index for functional disability scores. Results: Data was analysis by SPSS.25 on 74 patients. In type of pain, about 79% of patients were suffering from moderate and severe type of pain while there were only 21% of patients who came with mild pain in both groups. Independent t-test was applied for changes between the group on NPRS scale, the results shows significant results with p<0.05. In core stability group the difference between pretreatment and post treatment was 6.08 to 1.4 and in stability group the difference was 6.13 to 1.10. Endurance training exercises on ODI, there was no one with severe disability, and 94.6 %were with minimal disability and only 5.4 % were with moderate disability. It shows that endurance training exercises were better than stability exercises. Conclusion: It is concluded that endurance training has more clinical difference on outcome measures of NPRS and ODI as compared to core stability exercises in patients with mechanical low back pain.
Background: Surf practice contributes to overuse injuries and musculoskeletal pain. Relationship between the type of surfing practiced and the onset of pain is not fully understood as well as the potential role of rehabilitation in preventing it. Objective: To investigate musculoskeletal pain and to deepen whether the age and the anatomical region involved influenced the pain appearance in relation to four surfing disciplines. Methods: A cross-sectional study was carried out. An online survey was addressed to a group of Italian surfers (practicing surf, kitesurf, windsurf and stand up paddle since at least 1 year), collecting demographic data, discipline practiced, location of musculoskeletal pain. Results: One hundred and twenty-six surfers were involved in the study. Spine and upper limbs pain was more frequent compared to lower limbs one in the surf (p< 0.001) and in the windsurf groups (p= 0.007). In the kitesurf group a greater prevalence of pain was observed in spine and lower limbs compared to upper limbs (p= 0.017). Low back pain is the most represented among the spine pain subgroups (p< 0.001). Pain was lower in younger athletes (p= 0.007). Conclusions: Understanding risk factors and biomechanics of musculoskeletal pain is essential to realize prevention training strategies. Rehabilitation in sinergy with specific training allows pain-free activity, optimizing its overall health benefits.
Background: Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs. Objectives: The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments. Search methods: We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries ( and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update. Selection criteria: We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration. Data collection and analysis: Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo. Main results: We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias. Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups. Authors' conclusions: We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.
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Background: Pain is the most disabling characteristic of musculoskeletal disorders, and while exercise is promoted as an important treatment modality for chronic musculoskeletal conditions, the relative contribution of the specific effects of exercise training, placebo effects and non-specific effects such as natural history are not clear. The aim of this systematic review and meta-analysis was to determine the relative contribution of these factors to better understand the true effect of exercise training for reducing pain in chronic primary musculoskeletal pain conditions. Design: Systematic review with meta-analysis DATA SOURCES: MEDLINE, CINAHL, SPORTDiscus, EMBASE and CENTRAL from inception to February 2021. Reference lists of prior systematic reviews. Eligibility criteria: Randomised controlled trials of interventions that used exercise training compared to placebo, true control or usual care in adults with chronic primary musculoskeletal pain. The review was registered prospectively with PROSPERO (CRD42019141096). Results: We identified 79 eligible trials for quantitative analysis. Pairwise meta-analysis showed very low-quality evidence (GRADE criteria) that exercise training was not more effective than placebo (g [95% CI]: 0.94 [- 0.17, 2.06], P = 0.098, I2 = 92.4%, studies: n = 4). Exercise training was more effective than true, no intervention controls (g [95% CI]: 1.02 [0.67, 1.36], P < 0.001, I2 = 92.99%, studies: n = 42), usual-care controls (g [95% CI]: 0.65 [0.41, 0.89], P < 0.001, I2 = 84.82%, studies: n = 33), and when all controls combined (g [95% CI]: 0.86 [0.64, 1.07], P < 0.001, I2 = 91.37%, studies: n = 79). Conclusions: There is very low-quality evidence that exercise training is not more effective than non-exercise placebo treatments in chronic pain. Exercise training and the associated clinical encounter are more effective than true control or standard medical care for reductions in pain for adults with chronic musculoskeletal pain, with very low quality of evidence based on GRADE criteria.
Background: Currently, chronic pain is a disabling condition that is difficult to manage, which generates a high burden on health systems. The objective is to determine the effects of aerobic physical exercise in adults with chronic pain. Methods: A systematic review of searches in databases including MEDLINE, LILACS, ScienceDirect, PEDro, OTseeker, The Cochrane Library, EBSCO, and Google Scholar was conducted. The search process was carried out until July 31, 2020, and the study selection process was independently carried out through a criteria analysis for each phase. Outcome measures were chosen: aerobic capacity, physical function, quality of life, and pain. Results: Twenty-seven studies were included in which aerobic exercise was considered as an option to treat chronic pain. These studies showed significant results compared with other treatment options in terms of pain measurements (-0.22 [-0.42 to -0.03]) and aerobic capacity. For quality of life, there were significant improvements in the physical function component over the mental health component evaluated with the short form health survey-36/12. Conclusion: Aerobic exercise is a nonpharmacological therapeutic option for treatment. Also, aerobic capacity and endurance improved when this type of exercise was prescribed, thus resulting in a substantial improvement in the quality of life of people suffering from chronic pain.
Study Design: The contribution of transversus abdominis to spinal stabilization was evaluated indirectly in people with and without low back pain using an experimental model identifying the coordination of trunk muscles in response to a disturbance to the spine produced by arm movement. Objectives: To evaluate the temporal sequence of trunk muscle activity associated with arm movement, and to determine if dysfunction of this parameter was present in patients with low back pain. Summary of Background Data: Few studies have evaluated the motor control of trunk muscles or the potential for dysfunction of this system in patients with low back pain. Evaluation of the response of trunk muscles to limb movement provides a suitable model to evaluate this system. Recent evidence indicates that this evaluation should include transversus abdominis. Methods: While standing, 15 patients with low back pain and 15 matched control subjects performed rapid shoulder flexion, abduction, and extension in response to a visual stimulus. Electromyographic activity of the abdominal muscles, lumbar multifidus, and the contralateral deltoid was evaluated using fine‐wire and surface electrodes. Results: Movement in each direction resulted in contraction of trunk muscles before or shortly after the deltoid in control subjects. The transversus abdominis was invariably the first muscle active and was not influenced by movement direction, supporting the hypothesized role of this muscle in spinal stiffness generation. Contraction of transversus abdominis was significantly delayed in patients with low back pain with all movements. Isolated differences were noted in the other muscles. Conclusions: The delayed onset of contraction of transversus abdominis indicates a deficit of motor control and is hypothesized to result in inefficient muscular stabilization of the spine.
Objectives: To evaluate the effects of two different fitness programmes (water versus land based) on physical fitness level in patients with chronic low back pain.Design: Randomised controlled study.Subjects: Thirty patients with chronic low back pain randomly followed a land based fitness programme or an aquafitness programme.Methods: Subjects were evaluated with the Eurofit test battery for their physical fitness level. Both groups followed their programmes under supervision of a physiotherapist 3 days/week for 4 weeks.Results: Differences of measurements were not significant between the two groups. Significant differences were shown in both groups after the therapy programme with regard to aerobic fitness, motor fitness (single leg balance test with eyes open or closed), musculoskeletal fitness, pain reports, Sorensen and Oswestry low back pain disability index scores. No significant difference was found between the groups.Conclusion: Supervised aquafitness programmes have effects similar to those based on land fitness programmes on physical fitness level of chronic low back pain patients.
Objectives: To determine whether a functional-task exercise program and a resistance exercise program have different effects on the ability of community-living older people to perform daily tasks. Design: A randomized, controlled, single-blind trial. Setting: Community leisure center in Utrecht, the Netherlands. Participants: Ninety-eight healthy women aged 70 and older were randomly assigned to the functional-task exercise program (function group, n=33), a resistance exercise program (resistance group, n=34), or a control group (n=31). Participants attended exercise classes three times a week for 12 weeks. Measurements: Functional task performance (Assessment of Daily Activity Performance (ADAP)), isometric knee extensor strength (IKES), handgrip strength, isometric elbow flexor strength (IEFS), and leg extension power were measured at baseline, at the end of training (at 3 months), and 6 months after the end of training (at 9 months). Results: The ADAP total score of the function group (mean change 6.8, 95% confidence interval (CI)=5.2-8.4) increased significantly more than that of the resistance group (3.2, 95% CI=1.3-5.0; P=.007) or the control group (0.3, 95% CI=-1.3-1.9; P<.001). Moreover, the ADAP total score of the resistance group did not change significantly compared with that of the control group. In contrast, IKES and IEFS increased significantly in the resistance group (12.5%, 95% CI=3.8-21.3 and 8.6%, 95% CI=3.1-14.1, respectively) compared with the function group (-2.1%, 95% CI=-5.4-1.3; P=.003 and 0.3%, 95% CI=-3.6-4.2; P=.03, respectively) and the control group (-2.7%, 95% CI=-8.6-3.2, P=.003 and 0.6%, 95% CI=-3.4-4.6; P=.04, respectively). Six months after the end of training, the increase in ADAP scores was sustained in the function group (P=.002). Conclusion: Functional-task exercises are more effective than resistance exercises at improving functional task performance in healthy elderly women and may have an important role in helping them maintain an independent lifestyle.
The purpose of this study was to determine the influence of 2 different periodized exercise rehabilitation programs (resistance training [RT] and aerobic training [AT]) on musculoskeletal health, body composition, pain, disability, and quality of life (QOL) in chronic (>or=3 months; >or=3 d.wk) nonspecific low-back pain (CLBP) persons. Twenty-seven CLBP subjects were randomly assigned to 1 of 3 groups, 1) RT (n = 9), 2) AT (n = 9), or 3) control (C; n = 9). Subjects were tested at baseline and at weeks 8 and 16 of training. Intensity and volume were periodized in the training groups. Significance was set at p <or= 0.05. No significant differences were noted among the groups at baseline. The RT group significantly decreased body fat percent from baseline to week 8 and from baseline to week 16, whereas the AT group significantly decreased body fat percent and body mass from baseline to week 16. The RT group significantly improved most musculoskeletal fitness, pain, disability, and QOL outcomes from baseline to week 8, baseline to week 16, and weeks 8 to 16. However, the AT group showed significant improvements in flexibility from baseline to week 8 and in cardiorespiratory and peak leg power from baseline to week 8 and baseline to week 16. The AT groups showed no significant improvements in pain, disability, or QOL. The primary finding was that periodized RT was successful at improving many fitness, pain, disability, and QOL outcome measures, whereas AT was not. This study indicates that whole-body periodized RT can be used by training and conditioning personnel in the rehabilitation of those clients suffering with CLBP.
The physical performance of chronic pain patients is of major concern both for their assessment and for treatment evaluation. However, there are few widely used physical tests, a shortage of reliability and validity data on published tests, and an over-reliance on self-report or on clinical measures of dubious generalisability. A set of tests was designed to cover speed and endurance in walking, stair climbing, standing up from a chair, sit-ups, arm endurance, grip strength, and peak flow. Standard instructions and testing conditions were used by a trained tester on a population of chronic pain patients before and after a cognitive-behavioural chronic pain management programme. Reliability, validity, and acceptability of each test was examined, and recommendations made for their relative utility.