Core strengthening for chronic nonspecific low back pain: systematic review

Full text

Available online freely at www.isisn.org
Bioscience Research
Print ISSN: 1811-9506 Online ISSN: 2218-3973
Journal by Innovative Scientific Information & Services Network
RESEARCH ARTICLE BIOSCIENCE RESEARCH, 2018 15(4):4506-4519. OPEN ACCESS
Core strengthening for chronic nonspecific low back
pain: systematic review
Mahmoud Ahmed Elbayomy1,3, Lilian Albert Zaki1 and Ghada Koura1,2
1Physical Therapy for Orthopedics Department, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
2Medical Rehabilitation Department, Faculty of Applied Medical Science, KKU
3 Physical Therapy Department, Police Authority Hospitals, Egypt
*Correspondence: dr.bemo@live.com Accepted: 05Dec. 2018Published online: 31Dec. 2018
The term of core strengthening has been used to include lumbar stabilization, motor control training, and
other interventions focused on activation of the deep trunk muscles. This is systematic review and meta-
analysis aim to determine the efficacy, effectiveness of various core strengthening programs for adult
patients with chronic nonspecific low back pain. Present study measures self-reported pain, disability,
function and quality of life. We identified studies by searching multiple electronic databases from
inception to June 2018 and examining reference lists. We selected randomized controlled trials
comparing core strengthening exercises with sham, no treatment, other active therapies, and multimodal
therapeutic approaches. We assessed risk of bias using "PEDro" scale. We pooled data using random-
effects meta-analysis. We assessed the overall quality of the evidence using the GRADE approach.
Thirty four trials were included in the systematic review (n=2514). The majority of included studies had
low risk of bias .There is low to moderate evidence suggests that there is significant effect of core
strengthening exercise compared with general exercise on pain and disability at short and intermediate
term follow-up. There is very low to low evidence that there is significant effect favoring core
strengthening compared with multimodal physical therapy only on disability. Moderate evidence supports
no significant effect of core strengthening compared with manual therapy. There is low to moderate
evidence suggests that core strengthening results in reducing pain at all follow-up periods and reducing
disability at short term follow-up compared with minimal intervention. There is very low evidence that
there is significant effect favoring core strengthening compared with McKenzie exercises only on
disability. In patients with chronic low back pain there was no clinically important difference between
core strengthening and manual therapy but core strengthening exercises seem to be slightly superior to
several other treatments.
Keywords: back pain, exercise therapy, low back pain, core stability, systematic review, meta-analysis
INTRODUCTION
Core stabilization as a specific exercise
program has become the most popular treatment
method in spinal rehabilitation since it has shown
its effectiveness in some aspects related to pain
and disability. However, some studies have
reported that specific exercise program reduces
pain and disability in chronic but not in acute low
back pain, LBP (Ferreira et al., 2006).
Bergmark(1989) classified trunk muscles to a
global system and a local system control
movement, and stability in the spine. The global
system consists of the primary movers of the
spine such as the rectus abdominus, external
oblique. These muscles move the trunk but have
no direct attachment to the lumbar spine. The
local system includes stabilizing muscles of the
spine such as the psoas major,

Elbayomy et al., Core strengthening exercises
Bioscience Research, 2018 volume 15(4): 4506-4519 4507
quadratuslumborum, lumbar multifidus and the
transverse abdominis. These muscles have direct
attachments to the vertebrae and can therefore
provide stability. Whilst traditional exercises work
to increase the strength of the larger muscles
responsible for movement, the core strengthening
approaches (i.e. lumbar stabilization, dynamic
stabilization and motor control training) aim to
improve the dynamic stability role of the “local”
muscles (Richardson et al., 2002). Some
randomized controlled trials have
comprehensively reported the effects of core
stability exercises versus conventional
physiotherapy treatments on pain and disability in
chronic low back pain patients (Dankaerts et al.,
2006 and Liddle et al., 2007). These studies have
addressed the need of homogenous chronic low
back pain group for better clinical outcomes.
The objective of the present systematic review
was to investigate the short-term, intermediate,
and long-term effect of core strengthening
exercises in patients with chronic nonspecific LBP
by assessing the new RCTs in this topic.
MATERIALS AND METHODS
Search strategy for identifying study:
A computer search from inception to June
2018 of the following databases MEDLINE, The
Cochrane Central Register of Controlled Trials
(CENTRAL), Physiotherapy evidence data base
(PEDro), EMBASE and References of relevant
review articles and trials will be screened. The
following key words list for back pain conditions
and combined with medical subject heading
(MESH) of back pain and core strengthening
therapy. Nonspecific back pain, mechanical low
back pain, core stability, motor control, dynamic
stabilization, trunk stabilization exercise,
transversusabdominis, multifidus, neuromuscular
control, chronic and randomized controlled trial
(RCT).
Study selection:
We included RCTs published in English and
including Adult patients with chronic nonspecific
LBP. Back pain onset more than 12 weeks. Type
of intervention in included studies, all Studies
using one or more types of core strengthening
program. All type of core strengthening exercise
were included such as dynamic stabilization,
Motor control (neuromuscular) training, neutral
spine control and trunk stabilization. Type of
outcome measure: The outcomes of interest were
pain, work disability, quality of life and back
specific function. Publication in languages other
than English were excluded. RCTs that involve
subjects with LBP caused by specific pathological
entities such as infection, neoplasm, metastasis,
osteoporosis rheumatoid arthritis, or fracture are
excluded. RCTs that involve subjects with acute
or sub-acute nonspecific LBP (onset less than 12
weeks).
Assessment risk of bias (Methodological
quality of the studies):
All trials were scored according to10-point
"PEDro" scale. (Verhagen et al., 1998). The study
is considered high quality (Low risk of bias) RCT
when PEDro Scale scores ≥6.
Data Extraction and Analysis:
For all studies sample size, mean, and
standard deviation for each treatment group, at
each time point reported were extracted. The
meta-analysis compared mean values for pain,
disability, function and quality of life between core
strengthening exercises and other interventions.
Studies that used the same tools for outcome
assessment were compared using the mean
difference (MD) and 95% of the confidence
intervals (CI) to allow for direct comparison of the
results. If studies used different measurement
tools for the same outcome, the standardized
mean difference (SMD) and 95% of the (CI) were
calculated. Because heterogeneity was expected,
random-effect models were used. The
heterogeneity of the studies was evaluated by the
I2 statistic. The Cochrane Collaboration provides
the following interpretation of I2: 0%–30%, might
not be important; 30%–60%, may represent
moderate heterogeneity; 50%–90% represent
substantial heterogeneity, respectively (Higgins
and Green, 2011). All statistical analysis was
performed using the Review Manager (Rev Man
5.3). For the measurement of effect sizes, three
levels were defined: Standardized mean
differences of 0.2, 0.5, and 0.8 are equated to
effect sizes of small, medium, and large (Cohen,
1988). Outcome assessment data were
abstracted for 3 time periods: short term <3
months from randomization, intermediate-term
between 3 and 12 months and long-term ≥12
months from randomization (Hayden et al., 2005).
The GRADE system rated the quality of the
evidence for the most important outcomes in the
review. The GRADE system rated the quality of
evidence for each outcome, from a rating of HIGH
to VERY LOW. GRADE starts with a baseline
rating of HIGH for RCTs. Reasons to downgrade

Elbayomy et al., Core strengthening exercises
Bioscience Research, 2018 volume 15(4): 4506-4519 4508
the evidence quality are risk of bias,
inconsistency, indirectness, imprecision and
publication bias (Rayan and Hill, 2016). The
quality of evidence was downgraded due to .Risk
of bias (downgraded when more than 25% of the
participants were from studies with a high risk of
bias), or no change in the effect size after
conducting sensitivity analysis of high quality
studies. .Inconsistency (downgraded when
I2>50%).Indirectness (downgraded when an
indirect outcome measurement was present).
Imprecision (downgraded when<400 participants
were included) .Publication bias (downgraded
when an asymmetry of funnel plot was present),
or if all results come from small studies.
RESULTS
The searches retrieved 3183 records, of
which 81 full-text articles were assessed and a
total of 34 trials involving 2514 patient fulfilled the
inclusion criteria. Review progress is summarized
as a flow diagram in Figure 1. Characteristics of
the 34 included studies is presented in Table 1.
Risk of bias analysis of included studies:
We considered 18 RCTs, a total of 52.9% of
the included trials to have a low risk of bias (high
quality studies), representing 62.4% of all
participants (n=1568). Overall risk of bias
assessed by PEDro scale scores varied from 4 to
9 from a total of 10 points. The included studies
were sorted into the following categories in order
to attempt to create homogeneous subsets of
studies
 Core strengthening versus general
exercises.
 Core strengthening versus multimodal
physical therapy.
 Core strengthening versus manual
therapy.
 Core strengthening versus minimal
interventions.
 Core strengthening versus McKenzie
exercises.
Analysis
Core strengthening versus general exercise.
For primary outcomes, there is low evidence
suggest that core strengthening exercises result in
large reduction in pain at short term and
intermediate term [mean difference (MD) -1.18;
95,% confidence interval (CI) -1.68 to -0.67; 15
trials] at short term and [MD -0.92; 95% CI -1.5 to-
0.35; 8 trial] at intermediate term. And high
evidence that core strengthening exercises result
in a small possibly unimportant effect in pain at
long term [MD -0.11; 95% CI -0.52 to 0.31; 5
trials] as shown in Figure (2). There is low
evidence suggest that core strengthening
exercises result in a large reduction in disability at
short term [standardized mean difference (SMD) -
0.98; 95% CI -1.46 to -0.50; 14 trials], moderate
evidence that core strengthening exercises
probably reduce disability at intermediate term
[SMD -0.59; 95% CI -1.03 to -0.15; 8 trials] and
high quality evidence that core strengthening
exercises result in a small possibly unimportant
effect in disability at long term [SMD -0.04; 95%
CI -0.21 to 0.12; 4 trials]. In quality of life outcome
for physical component there is low evidence
suggests core strengthening exercises improve
quality of life slightly at short term [MD 3.97; 95%
CI -4.25 to 12.18; 2 trials] and at intermediate
term [MD 2.67; 95% CI -3.40 to 8.75; 3 trials]. And
moderate evidence that core strengthening
exercises likely result in small possibly
unimportant improvement in quality of life at long
term [MD 0.08; 95% CI -3.14 to 3.30; 2 trial]. For
mental component there is moderate evidence
suggests core strengthening exercises likely result
in small possibly unimportant improvement in
quality of life at short term [MD 1; 95% CI -1.68 to
3.89; 2 trials]. And moderate evidence that
general exercises likely result in small possibly
unimportant improvement in quality of life more
than core strengthening exercises at intermediate
term [MD -0.61; 95% CI -3.15 to 1.93; 3trial] and
at long term [MD -0.75; 95% CI -3.32 to 1.82; 2
trial]. There is low evidence suggests core
strengthening exercises improve function at short
term follow-up slightly [SMD 0.34; 95% CI 0.01 to
0.67; 2 trials], moderate evidence suggests core
strengthening likely result in a small probably
unimportant effect in function at intermediate term
[SMD 0.10; 95% CI -0.12 to 0.31; 2 trials] and low
evidence suggests that core strengthening may
result in a very small unimportant improvement in
function at long term [SMD 0.08; 95% CI -0.26 to
0.42; 2 trials].
Core strengthening versus multimodal
physical therapy.
There is very low evidence suggests core
strengthening may reduce pain at short time
follow-up but we are very uncertain [MD -0.35;
95% CI -0.99 to 0.29; 6 trials].There is low
evidence suggests that core strengthening result
in a medium reduction in disability at short term
follow-up [SMD -0.5; 95% CI -0.87 to -0.13; 3

Elbayomy et al., Core strengthening exercises
Bioscience Research, 2018 volume 15(4): 4506-4519 4509
trials].
(Figure 1): Flowchart of the study.

Elbayomy et al., Core strengthening exercises
Bioscience Research, 2018 volume 15(4): 4506-4519 4510
Table 1: Characteristics of the included studies (sorted by study ID)
Study ID / number
of participants
Intervention
Outcomes
PEDro score/
risk of bias
Akbaria 2008
(n=49)
Motor control exercise (MCE)(n=25) and
General exercise (n=24) 16 sessions for
8 weeks
Pain: visual
analog scale(VAS)
5/10
high risk of bias
Akhtar 2017
(n=120)
Core stabilization exercise (CSE) (n=60)
and routine physical therapy (PT) (n=60)
1 session per week / 6 weeks
Pain: VAS
5/10
high risk of bias
Alp 2014
(n=48)
CSE (n=24) for 6 weeks 3 times per
week and home based exercise (n=24)
Pain: VAS
Disability :Ronald
Morris disability questionnaire
( RMDQ) Quality of life: SF-36
6/10
low risk of bias
Bhadauria 2017
(n=44)
Lumbar stabilization (n=15) dynamic
strengthening (n=14) Pilates (n=15) 10
sessions for 3 weeks
Pain: VAS
Disability: Oswestry
disability index (ODI)
7/10
Low risk of bias
Cairns 2006
(n=97)
Conventional PT (n=50) and spinal
stabilization (n=47). 12 session per 12
weeks
Pain: VAS Disability RMDQ
Quality of life: sf-36
7/10
Low risk of bias
Costa 2009
(n=154)
MCE (n=77) and placebo (n=77). 12
sessions over 8 weeks.
Pain: numerical
rating scale (NRS)
Disability: RMDQ
Function: patient-
specific function scale (PSFS)
9/10
Low risk of bias
Critchley 2007
(n=212)
Usual PT (n=71), spinal stabilization
(n=72) 8 session of 90 minutes and pain
management classes (n=69)
Pain: NRS
Disability: RMDQ
7/10
Low risk of bias
Ferreira 2007
(n=240)
MCE (n=80), general exercise (n=80)
and spinal manipulative therapy (n=80).
12 sessions over 8 weeks
Pain: VAS
Disability: RMDQ Function:
PSFS
8/10
Low risk of bias
Franca 2010
(n=30)
Segmental stabilization (n=15) and
strengthening exercises (n=15)
2sessions per week for 6 weeks
Pain: VAS Disability: ODI
7/10
Low risk of bias
Franca 2012
(n=30)
Segmental stabilization (n=15) and
stretching exercises (n=15) 2sessions
per week for 6 weeks
Pain: VAS Disability: ODI
8/10
Low risk of bias
Ghaderi 2016
(n=60)
Multimodal PT (n=30) and CSE+ PT
(n=30). 12 weeks program.
Pain: VAS Disability: ODI
4/10
High risk of bias
Goldby 2006
(n=346)
Manual therapy (n=89), spinal
stabilization exercise (n=84) for 10
weeks and minimal intervention (n=40).
Pain: NRS Disability :ODI
4/10
High risk of bias
Halliday 2016
(n=70)
MCE (n=35) and McKenzie (n=35).12
sessions/ 8 weeks
Pain: VAS Function: PSFS
7/10
Low risk of bias
Hosseinifar 2013
(n=30)
CSE (n=15) and McKenzie (n=15).18
sessions/ 6 weeks
Pain: VAS Disability:
Functional rating index
5/10
High risk of bias
Inani 2013
(n=30)
CSE (n=15) was given in 4 phases and
conventional exercise (n=15) for 3
months
Pain: VAS Disability: ODI
6/10
Low risk of bias
Javadian 2012
(n=30)
routine exercises
(n=15) and routine exercises plus CSE
(n=15) for 8 weeks
Pain: VAS Disability : ODI
4/10
High risk of bias
Kachanathu 2012
(n=30)
CSE (n=15) and
Lumbar flexion and extension exercise
(n=15). For 8 weeks.
Pain: VAS Disability :ODI
4/10
High risk of bias
Kang 2016
(n=20)
Exhalations exercises (n=10) and spinal
SE (n=10). 24 sessions/ 6 weeks
Disability: ODI
4/10
High risk of bias
Kim 2013
(n=16)
Neurac sling CSE + ordinary PT (n=8)
and ordinary PT (n=8). 4 times per week
Pain: VAS Disability : ODI
4/10
High risk of bias

Elbayomy et al., Core strengthening exercises
Bioscience Research, 2018 volume 15(4): 4506-4519 4511
Table 1: Characteristics of the included studies (continued)
Study ID /
number of
participants
Intervention
Outcomes
PEDro score/
risk of bias
Lomond 2015
(n=33)
SE (n=12) and Movement
System Impairment based
treatment (n=21). For 6 weeks.
Pain: NRS
Disability: ODI
7/10
Low risk of bias
Macedo 2012
(n=172)
MCE (n=86) and graded activity
(n=86) 14 sessions/ 8 weeks. 2
sessions at 4th 10th
month from randomization
Pain: NRS
Disability: RMDQ
Function: PSFS
Quality of life: (SF-36)
8/10
Low risk of bias
Moon 2013
(n=21)
Lumbar SE (n=11) and
strengthening exercise (n=10).16
sessions / 8 weeks
Pain: VAS
Disability: ODI
6/10
Low risk of bias
Nabavi 2018
(n=41)
SE+ electrotherapy (n=20) and
routine exercise +electrotherapy
(n=21). 3 times a week / 4 weeks
Pain: VAS
5/10
High risk of bias
Park 2013
(n=24)
Lumbar SE (n=8), control group
(n=8) and Nintendo Wii exercises
(n=8). 3 times a week / 8 weeks.
Pain: VAS
5/10
High risk of bias
Puntumetakul
2013
(n= 42)
CSE (n=21) and conventional
exercises (n=21). 20minutes
twice a week /10 weeks
Pain: NRS
Disability: RMDQ
Quality of life: (SF-36)
8/10
Low risk of bias
Rabin 2014
(n=105)
SE (n=48) manual therapy
(n=57) 11 sessions/8 weeks
Pain: NRS
Disability: ODI
6/10
Low risk of bias
Rasmussen-
Barr 2009
(n=71)
Graded SE (n=36) and daily walk
(n=35) for 8 weeks
Pain: VAS
Disability: ODI
7/ 10
Low risk of bias
Salamat 2017
(n=32)
SE (n=16) and movement control
group (n=16). 8 sessions / 4
weeks
Pain: NRS
Disability: ODI
4/10
High risk of bias
Salavati 2016
(n=40)
SE (n=20) and routine PT
(n=20). 12 sessions/4 weeks
Pain: VAS
Disability: ODI
5/10
High risk of bias
Shaughnessy
2004
(n=41)
Lumbar SE (n=20) and control
group (n=21).10 session/ 10
weeks
Disability: ODI
5/10
High risk of bias
Soundararajan
2016
(n=30)
multifidus retraining program
(n=15) and traditional exercise
(n=15) for 6 weeks
Pain: VAS
Disability: ODI
4/10
High risk of bias
Tsauo 2009
(n=37)
Trunk SE (n=20), traditional
rehabilitation program (n=17).
100 hour/ 3 months
Pain: NRS
Disability: ODI
4/10
High risk of bias
Unsgaard-
Tondel 2010
(n=109)
MCE (n=36), sling exercise
(n=36) and general exercise
(n=37) for 8 weeks
Pain: NRS
Disability: ODI
7/10
Low risk of bias
Wang 2012
(n=60)
CSE (n=32) and traditional
exercise (n=28) for 12 weeks
Pain: NRS
Disability: ODI
9/10
Low risk of bias

Elbayomy et al., Core strengthening exercises
Bioscience Research, 2018 volume 15(4): 4506-4519 4512
(Figure 2): Forest plot of comparison: core strengthening versus general exercises, outcome:
pain.

Elbayomy et al., Core strengthening exercises
Bioscience Research, 2018 volume 15(4): 4506-4519 4513
Core strengthening versus manual therapy.
There is moderate evidence suggests that
core strengthening likely result in a small probably
unimportant effect in pain at short term follow-up
[MD -0.39; 95% CI -0.98 to 0.2; 2 trials], at
intermediate term [MD -0.55; 95% CI-1.39 to 0.29;
3 trials] and at long term follow-up [MD -0.26; 95%
CI -0.87 to 0.35; 3 trials] .There is moderate
evidence suggests that core strengthening likely
result in a small probably unimportant effect in
disability at short term follow-up [SMD -0.12; 95%
CI -0.40 to 0.16; 2 trials], at intermediate term
[SMD -0.09; 95% CI-0.31 to 0.12; 3 trials] and at
long term follow-up [SMD -0.07; 95% CI -0.27 to
0.13; 3 trials] (Figure3). There is low evidence
suggests that core strengthening result in small
effect that may be unimportant improvement in
function at short term follow-up [SMD 0.03; 95%
CI -0.28 to 0.34; 1trial] and at long term follow-up
[SMD 0.07; 95% CI -0.24 to 0.38; 1 trial] and low
evidence suggests that manual therapy may result
in small unimportant improvement in function
more than core strengthening at intermediate
follow-up [SMD -0.13; 95% CI -0.44 to 0.18;
1trial].
Core strengthening versus minimal
interventions.
There is moderate evidence suggests that
core strengthening result in a medium effect in
reducing pain at short term follow-up [MD -1.26;
95% CI -1.85 to -0.67; 2 trials] and long term
follow-up [MD -1.3; 95% CI -1.85 to -0.74; 3 trials]
and low evidence supports this effect at
intermediate follow-up [MD -1.25; 95% CI -2.01 to
-0.49; 4 trials] (figure 4).There is low evidence
suggests that core strengthening result in a
medium reduction in disability at short term follow-
up [SMD -0.66; 95% CI -1.08 to -0.24; 3 trials] and
low evidence suggests core strengthening reduce
disability slightly at intermediate term [SMD -0.37;
95% CI -0.75 to 0.02; 4 trials] and at long term
follow-up [SMD -0.29; 95% CI -0.73 to 0.14; 3
trials].There is low evidence suggests that core
strengthening improve function slightly at short
term follow-up [SMD 0.47; 95% CI 0.15 to 0.79; 1
trial] and at intermediate term follow-up [SMD
0.38; 95% CI 0.06 to 0.69; 1 trial] and low
evidence suggests core strengthening result in a
medium improvement in function at long term
follow-up [SMD 0.57; 95% CI 0.25 to 0.90; 1 trial].
Core strengthening versus McKenzie.
There is very low evidence suggests core
strengthening may result in small reduction in pain
at short term follow-up [MD -0.55; 95% CI -1.75 to
0.65; 2 trials] but we are very uncertain. There is
very low evidence suggests that core
strengthening may reduce disability at short term
follow-up [SMD -1.13; 95% CI -1.91 to -0.35; 1
trial] but we are very uncertain. There is low
evidence suggests that McKenzie exercises may
improve function more than core strengthening
slightly at short term follow-up [SMD -0.32; 95%
CI -0.82 to 0.18; 1 trial]
DISCUSSION
In the comparison of core strengthening
versus general exercise there is statistical
significant effect of core strengthening exercises
in reducing pain and disability in short term and
intermediate term follow-up and high quality
evidence that there is no statistical important
effect in reducing pain and disability at long term
follow-up. There is no statistical significant effect
in improving quality of life at all follow-up periods.
Core strengthening exercises have a small
unimportant statistical effect in improving function
at short term follow-up. In the comparison of core
strengthening versus multimodal physical therapy
there is no statistical significant effect of core
strengthening exercises in reducing pain at short
term follow-up and low evidence there is a
moderate statistical effect of core strengthening
exercise in reducing disability at short term follow-
up. In the comparison of core strengthening
versus manual therapy there is moderate quality
of evidence that there is no statistical significant
effect of core strengthening exercises in reducing
pain and disability at all follow-up periods and low
evidence that there is no statistical significant
effect of core strengthening exercises in improving
function at all follow-up periods. In the comparison
of core strengthening versus minimal interventions
there is low to moderate quality evidence that
there is moderate statistical effect of core
strengthening exercise in reducing pain at all
follow-up periods. There is low evidence there is a
moderate statistical effect of core strengthening
exercise in reducing disability at short term follow-
up and low quality of evidence that there is no
statistical significant effect of core strengthening
exercises in reducing disability at intermediate
and long term follow-up periods. Low evidence
supports a small to medium statistical effect of
core strengthening exercises in improving function
at all follow-up periods.

Elbayomy et al., Core strengthening exercises
Bioscience Research, 2018 volume 15(4): 4506-4519 4514
(Figure 3): Forest plot of comparison: core strengthening versus manual therapy, outcome:
disability.

Elbayomy et al., Core strengthening exercises
Bioscience Research, 2018 volume 15(4): 4506-4519 4515
(Figure 4): Forest plot of comparison: core strengthening versus minimal interventions, outcome:
pain.
In the comparison of core strengthening
versus McKenzie exercises there is no statistical
significant effect of core strengthening exercises
in reducing pain, very low quality of evidence that
there is a statistical significant effect of core
strengthening exercises in reducing disability and
there is no statistical significant effect of core
strengthening exercises in improving function at
short term follow-up. The findings from the
previous systematic reviews of core stability
exercise or motor control exercise (MCE) for LBP
are partially consistent with our results. Bystrom et
al., (2013) reported significant effect of MCE
compared with general exercise on pain at short
and intermediate term follow-up which is
consistent with our results while Saragiotto et al.
(2016) report significant effect at short term follow-
up only. Wang et al. (2012a) and Bystrom et al.,

Elbayomy et al., Core strengthening exercises
Bioscience Research, 2018 volume 15(4): 4506-4519 4516
(2013) reported a statistically significant effect on
disability favoring MCE and core stability
exercises compared with general exercise at all
follow-up periods while, Saragiotto et al., (2016)
reported significant effect only at short term. Our
results reported significant effect at short term and
intermediate term follow-up periods. Two previous
systematic reviews, Saragiotto et al., (2016) and
Bystrom et al., (2013) reported significant effect of
MCE compared with multimodal physical therapy
on pain and disability these results are
inconsistent with our results which reported
significant effect favoring core strengthening only
on disability and no significant effect on pain.
When comparing core stability exercises or MCE
with manual therapy, the previous reviews
(Saragiotto et al., 2016, Bystrom et al., 2013 and
Macedo et al., 2009) did not find a significant
effect of MCE or reported small effect which is
consistent with our results. In the comparison of
motor control exercises versus minimal
intervention three previous reviews (Saragiotto et
al., 2016, Bystrom et al., 2013 and Macedo et al.,
2009) reported a clinically important effect of MCE
compared with minimal intervention, these results
are consistent with our results with regarding to
pain at all follow-up periods and disability at short
term follow-up. No previous systematic review
compare effect of core strengthening exercises
with McKenzie exercises. This divergence in
findings may be explained because these reviews
included some RCTs that containing some sub-
acute back pain patients that were excluded from
our review and due to recent RCTs included in our
review. Publication bias may be created because
of non-English relevant articles which met the
inclusion criteria may show positive or negative
results but were not included in our review.
CONCLUSION
Core strengthening exercises reduce pain and
disability at short and intermediate term more than
general exercises, level of evidence range from
low to moderate. Low evidence support core
strengthening reduce disability more than
multimodal physical therapy. There was no
clinically important difference between core
strengthening and manual therapy. Low to
moderate evidence suggest core strengthening
has significant effect on pain more than minimal
intervention at all follow-up periods and on
disability at short term follow-up. The effect of
core strengthening compared with McKenzie
exercises is very uncertain.
CONFLICT OF INTEREST
The authors declared that present study was
performed in absence of any conflict of interest.
ACKNOWLEGEMENT
The authors would thank their parents all
authors of RCTs included in this study.
Copyrights: © 2017 @ author (s).
This is an open access article distributed under the
terms of the Creative Commons Attribution License
(CC BY 4.0), which permits unrestricted use,
distribution, and reproduction in any medium,
provided the original author(s) and source are
credited and that the original publication in this
journal is cited, in accordance with accepted
academic practice. No use, distribution or
reproduction is permitted which does not comply
with these terms.
REFERENCES
Akbaria, A., Khorashadizadeh S., Abdi G (2008).
The effect of motor control exercise versus
general exercise on lumbar local stabilizing
muscles thickness: randomized controlled
trial of patients with chronic low back pain.
Journal of Back and Musculoskeletal
Rehabilitation; 21(2):105-112.
Akhtar, M. W., Karimi, H., &Gilani, S. A. (2017).
Effectiveness of core stabilization exercises
and routine exercise therapy in management
of pain in chronic nonspecific low back pain:
A randomized controlled clinical trial.
Pakistan Journal of Medical Sciences, 33(4),
1002–1006.
Alp, A., Mengi, G., Avşaroǧlu, A. H., Mert, M.,
&Siirli, D. (2014).Efficacy of Core-
Stabilization Exercise and Its Comparison
with Home-Based Conventional Exercise in
Low Back Pain Patients.TurkiyeFiziksel Tip
ve RehabilitasyonDergisi, 60 (SUPPL. 1),
36–42.
Bergmark A (1989): Stability of the lumbar spine:
a study in mechanical engineering.
ActaOrthopScand Suppl.; 230:1-54.
Bhadauria, E .A.&Gurudut, P. (2017).
Comparative effectiveness of lumbar
stabilization, dynamic strengthening, and
Pilates on chronic low back pain: randomized
clinical trial. Journal of Exercise
Rehabilitation ;( 4):477-485.
Bystrom MG, Rasmussen-Barr E, Grooten WJ.
(2013).Motor control exercises reduces pain
and disability in chronic and recurrent low

Elbayomy et al., Core strengthening exercises
Bioscience Research, 2018 volume 15(4): 4506-4519 4517
back pain: a meta-analysis. Spine; 38:E350–
8.
Cairns, M. C., Foster, N. E., & Wright, C.
(2006).Randomized Controlled Trial of
Specific Spinal Stabilization Exercises and
Conventional Physiotherapy for Recurrent
Low Back Pain.Spine, 31(19), E670–E681.
Cohen, J. (1988).Statistical Power Analysis for the
Behavioral Sciences (2nd Ed.). Hillsdale, NJ:
Lawrence Erlbaum Associates, Publishers.
Costa, L. O. P., Maher, C. G., Latimer, J.,
Hodges, P. W., (2009). Motor control
exercise for chronic low back pain: a
randomized placebo-controlled trial. Physical
Therapy 2009 Dec;89(12):1275-1286,
89(12), 1275–1286.
Critchley D.J., Ratcliffe J., Noonan S., et al
(2007). Effectiveness and Cost-Effectiveness
of Three Types of Physiotherapy Used to
Reduce Chronic Low Back Pain Disability.
SPINE, 32(14), 1474–1481.
Dankaerts W, O’Sullivan P, Burnett A, Straker L.
(2006): Altered patterns of superficial trunk
muscle activation during sitting in nonspecific
chronic low back pain patients: importance of
sub-classification. Spine 31(17): 2017-23.
Ferreira ML,Ferreira PH. Latimer J, et al. (2007).
Comparison of general exercise, motor
control exercise and spinal manipulative
therapy for chronic low back pain: a
randomized trial. Pain; 131(1-2):31-37.
Ferreira PH, Ferreira ML, Maher CG, and Herbert
RD, Refshauge K. (2006): Specific
stabilization exercise for spinal and pelvic
pain: a systematic review. Aust J Physiother;
52(2): 79-88.
Franca F. R., Burke T., Hanada E. S, et al(2010).
Segmental stabilization and muscular
strengthening in chronic low back pain: a
comparative study. Clinics (Sao Paulo,
Brazil); 10:1013-1017.
França FR, Burke T.,Caffaro R et al (2012).
Effects of muscular stretching and segmental
stabilization on functional disability and pain
in patients with chronic low back pain: a
randomized, controlled trial [with consumer
summary]. Journal of Manipulative and
Physiological Therapeutics;35(4):279-285.
Ghaderi, F., Mohammadi, K., Amir Sasan, R.,
NikoKheslat, S., &Oskouei, A. E.
(2016).Effects of Stabilization Exercises
Focusing on Pelvic Floor Muscles on Low
Back Pain and Urinary Incontinence in
Women.Urology, 93, 50–54.
Goldby, L. J., Moore, A. P., Doust, J., &Trew, M.
E. (2006).A Randomized Controlled Trial
Investigating the Efficiency of
Musculoskeletal Physiotherapy on Chronic
Low Back Disorder.Spine, 31(10), 1083–
1093.
Halliday, M. H., Pappas, E., Hancock, M. J.,
Clare, H. A., Pinto, R. Z.(2016). A
randomized controlled trial comparing the
McKenzie method to motor control exercises
in people with chronic low back pain and a
directional preference [with consumer
summary]. The Journal of Orthopaedic and
Sports Physical Therapy 2016 Jul;46(7):514-
522, 46(7), 514–522.
Higgins JPT, Green S (2011). Cochrane
Handbook for Systematic Reviews of
Interventions Version 5.1.0 [updated March
2011]. The Cochrane Collaboration,
Available from http://handbook.cochrane.org.
Hosseinifar, M. (2013). The Effects of Stabilization
and Mckenzie Exercises on Transverse
Abdominis and Multifidus Muscle Thickness,
Pain, and Disability: A Randomized
Controlled Trial in Non-Specific Chronic Low
Back Pain. Journal Of Physical Therapy
Science, 25(12), 1541–1545.
Inani, S. B., &Selkar, S. P. (2013). Effect of core
stabilization exercises versus conventional
exercises on pain and functional status in
patients with non-specific low back pain: A
randomized clinical trial. Journal of Back and
Musculoskeletal Rehabilitation, 26(1), 37–43.
Javadian, Y., Behtash, H., Akbari, M., Taghipour-
Darzi, M., &Zekavat, H. (2012).The effects of
stabilizing exercises on pain and disability of
patients with lumbar segmental
instability.Journal of Back and
Musculoskeletal Rehabilitation, 25(3), 149–
155.
Kachanathu, S. J., Zakaria, A. R., Sahni, A.,
&Jaiswal, P. (2012). Chronic Low Back Pain
in Fast Bowlers a Comparative Study of Core
Spinal Stabilization and Conventional
Exercises. Journal of Physical Therapy
Science, 24(9), 821–825.
Kang J.I, Jeong D.K, Choi H. (2016).Effect of
exhalation exercise on trunk muscle activity
and Oswestry Disability Index of patients with
chronic low back pain.Journal of Physical
Therapy Science; 28(6):1738-1742.
Kim J., KIM Y.E, Bae. S. H. (2013). The effect of
the Neurac sling exercise on postural
balance adjustment and muscular response
patterns in chronic low back pain patients.
Journal of Physical Therapy Science;

Elbayomy et al., Core strengthening exercises
Bioscience Research, 2018 volume 15(4): 4506-4519 4518
25(8):1015-1019.
Liddle SD, Gracey JH, Baxter GD (2007):Advice
for the management of low back pain: a
systematic review of randomized controlled
trials. Man Ther; 12(4): 310-27.
Lomond, K. V, Jacobs, J. V, Hitt, J. R., DeSarno,
M. J, et al. (2015). Effects of low back pain
stabilization or movement system impairment
treatments on voluntary postural
adjustments: a randomized controlled trial.
The Spine Journal: Official Journal of the
North American Spine Society, 15(4), 596–
606.
Macedo LG, LatimerJ., Maher CG (2012). Effect
of motor control exercises versus graded
activity in patients with chronic nonspecific
low back pain: a randomized controlled trial.
Physical Therapy; 92(3):363-377.
Macedo LG, Maher CG, Latimer J, et al (2009).
Motor control exercisefor persistent,
nonspecific low back pain: a systematic
review. PhysTher; 89:9–25.
Moon, H. J., Choi, K. H., Kim, D. H., Kim, H. J.,
Cho, Y. K (2013). Effect of lumbar
stabilization and dynamic lumbar
strengthening exercises in patients with
chronic low back pain. Annals of
Rehabilitation Medicine, 37(1), 110–117.
Nabavi, N., MA, M. B., Mosallanezhad, Z.,
Rahgozar, M., &Jaberzadeh, S. (2018). The
Effect of 2 Different Exercise Programs on
Pain Intensity and Muscle Dimensions in
Patients With Chronic Low Back Pain: a
Randomized Controlled Trial. Journal of
Manipulative and Physiological
Therapeutics41 (2), 102–110.
Park J.H, Lee S.H, KO D.S. (2013). The effects of
the Nintendo Wii exercise program on
chronic work-related low back pain in
industrial workers. Journal of Physical
Therapy Science; 25(8):985-988.
Puntumetakul, R., Areeudomwong, P., Emasithi,
A., & Yamauchi, J. (2013).Effect of 10-week
core stabilization exercise training and
detraining on pain-related outcomes in
patients with clinical lumbar instability.Patient
Preference and Adherence, 7, 1189–1199.
Rabin, A., Shashua, A., Pizem, K., Dickstein, R.,
& Dar, G. (2014). A Clinical Prediction Rule
to Identify Patients With Low Back Pain Who
Are Likely to Experience Short-Term
Success Following Lumbar Stabilization
Exercises: A Randomized Controlled
Validation Study. Journal of Orthopaedic&
Sports Physical Therapy, 44(1), 6-B13.
Rasmussen-Barr, E., Ang, B., Arvidsson, I., &
Nilsson-Wikmar, L. (2009). Graded exercise
for recurrent low-back pain: a randomized,
controlled trial with 6-, 12-, and 36-month
follow-ups. Spine, 34(3), 221–228.
Rayan R, Hill S (2016).How to GRADE the quality
of the evidence. Cochrane Consumers and
Communication Group, available
athttp://cccrg.cochrane.org/author-resources.
Review Manager (RevMan) [Computer
program].Version 5.3. Copenhagen: The
Nordic Cochrane Centre, The Cochrane
Collaboration, 2014.
Richardson, C.A., Snijders, C.J., Hides, J.A.,
Damen, L., Pas, M.S. & Storm, J. (2002):
The relation between the transverse
abdominis muscles, sacroiliac joint
mechanics, and low back pain. Spine; 27,
399-405.
Salamat, S., Talebian, S., Bagheri, H., Maroufi,
N., M, J. S., Kalbasi, G., & O’Sullivan, K.
(2017). Effect of movement control and
stabilization exercises in people with
extension related non-specific low back pain-
a pilot study. Journal of Bodywork &
Movement
Therapieshttp://dx.doi.org/10.1016/j.jbmt.201
7.02.005.
Salavati, M., Akhbari, B., Takamjani, I. E.,
Bagheri, H., Ezzati, K., &Kahlaee, A. H.
(2016).Effect of spinal stabilization exercise
on dynamic postural control and visual
dependency in subjects with chronic non-
specific low back pain.Journal of Bodywork
and Movement Therapies, 20(2), 441–448.
Saragiotto Bruno T, Maher Christopher G,
YamatoTieˆ P et al. (2016).Motor Control
Exercise for Nonspecific
LowBackPain.SPINE; 41(16):1284–1295.
Shaughnessy, M., & Caulfield, B. (2004).A pilot
study to investigate the effect of lumbar
stabilisation exercise training on functional
ability and quality of life in patients with
chronic low back pain.Int J Rehabil Res,
27(4), 297–301.
Soundararajan, L. R. A., &Thankappan, S. M.
(2016).Efficacy of the Multifidus Retraining
Program in Computer Professionals with
Chronic Low Back Pain.Asian Spine Journal,
10(3), 450–456.
Tsauo j, Chen, W. Liang H., Jang Y. (2009).The
effectiveness of a functional training
programme for patients with chronic low back
pain -- a pilot study.Disability and
Rehabilitation;31(13):1100-1106.

Elbayomy et al., Core strengthening exercises
Bioscience Research, 2018 volume 15(4): 4506-4519 4519
Unsgaard-Tondel, M., Fladmark, A. M., Salvesen,
O., &Vasseljen, O. (2010). Motor control
exercises, sling exercises, and general
exercises for patients with chronic low back
pain: a randomized controlled trial with 1-
year follow-up [with consumer summary].
Physical Therapy;90(10):1426-1440.
Verhagen AP, de Vet HCW, de Bie RA, et al
(1998): The Delphi List: a criteria list for
quality assessment of randomized clinical
trials for conducting systematic reviews
developed by Delphi consensus. J
ClinEpidemiol.; 51:1235–1241.
Wang XQ, Zheng JJ, Yu ZW, et al (2012).A meta-
analysis of corestability exercise versus
general exercise for chronic low
backpain.PLoS One; 7 (12):e52082.
Wang, W. X. Jiejiaæ, Z. Xia B. (2012).Effect of
core stability training on patients with chronic
low back pain.Health MED; 6(3):754-759.