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The effects of the CORE programme on pain at rest, movement-induced and

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workers with chronic low back pa...

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research-article2014
CRE0010.1177/0269215514552082Clinical RehabilitationKim et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

The effects of the CORE 2015, Vol. 29(7) 653­–662

© The Author(s) 2014
Reprints and permissions:
programme on pain at rest, sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0269215514552075

movement-induced and secondary cre.sagepub.com

pain, active range of motion, and

proprioception in female office
workers with chronic low back pain:
a randomized controlled trial

Tae Hoon Kim1,*, Eun-Hye Kim2,* and Hwi-young Cho3

Abstract
Objective: To investigate the effects of the CORE programme on pain at rest, movement-induced pain,
secondary pain, active range of motion, and proprioception deficits in female office workers with chronic
low back pain.
Design: Randomized controlled trial.
Setting: Rehabilitation clinics.
Subjects: A total of 53 participants with chronic low back pain were randomized into the CORE group
and the control group.
Intervention: CORE group participants underwent the 30-minute CORE programme, five times per
week, for eight weeks, with additional use of hot-packs and transcutaneous electrical nerve stimulation,
while the control group used only hot-packs and transcutaneous electrical nerve stimulation.
Main measures: Participants were evaluated pretest, posttest, and two months after the intervention
period to measure resting and movement-induced pain, pressure pain as secondary pain, active range of
pain-free motion, and trunk proprioception.
Results: Pain intensity at rest (35.6 ±5.9 mm) and during movement (39.4 ±9.1 mm) was significantly
decreased in the CORE group following intervention compared with the control group. There were
significant improvements in pressure pain thresholds (quadratus lumborum: 2.2 ±0.7 kg/cm2; sacroiliac joint:
2.0 ±0.7 kg/cm2), active range of motion (flexion: 30.8 ±14.3°; extension: 6.6 ±2.5°), and proprioception
(20° flexion: 4.3 ±2.4°; 10° extension: 3.1 ±2.0°) in the CORE group following intervention (all p < 0.05).

1The Post-Professional DPT Program, The Richard Stockton
College of New Jersey, Galloway, NJ, USA
2Department of Physical Therapy, Korea University, Seoul,
South Korea
3Department of Physical Therapy, Gachon University, Incheon,
South Korea
*Two authors are equally contributed to this study.
Corresponding author:
Hwi-young Cho, Department of Physical Therapy, College
of Health Science, Gachon University, 191 Hambangmoe-ro,
Yeonsu-gu, Incheon, 406-799, Republic of Korea.
Email: hwiyoung@gachon.ac.kr

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654 Clinical Rehabilitation 29(7)

These improvements were maintained at the two-month follow-up. The control group did not show
significant improvements in any measured parameter.
Conclusion: The CORE programme is an effective intervention for reducing pain at rest and movement-
induced pain, and for improving the active range of motion and trunk proprioception in female office
workers with chronic low back pain.

Keywords
Movement-induced pain, CORE programme, chronic low back pain, proprioception, active range of
motion

Received: 1 August 2013; accepted: 28 August 2014

Introduction
Low back pain is the most common disorder in
modern society.1 Female office workers, in particu-
lar, have a higher risk of developing chronic low
back pain.2
Chronic low back pain patients tend to minimize
trunk movement to alleviate lumbar pain, which, in
turn, aggravates lumbar muscle weakness of the par-
aspinal and multifidus muscles.3 In addition to mus-
cular inhibition, patients who experience chronic
low back pain demonstrate impaired proprioception,
which is the sense of position and movement of the
human body, and this impairment causes motion
error and motor function deficit.4 Owing to these
functional deficits, chronic low back pain patients
show altered muscle recruitment patterns and differ-
ences in motor control, such as delayed reflex
latency and poor postural control.5,6 Consequently,
improvements in muscle strength and propriocep-
tion are novel therapeutic goals of chronic low back
pain rehabilitative programmes. Although some sys-
tematic reviews have reported the effects of various
core stability exercises on low back pain in the past
decade, there is currently a growing interest in the
ability of these exercises to change certain aspects of
physical function, such as muscle strength, mobility,
and muscular endurance.7,8
A variety of exercise programmes have been
recommended to facilitate chronic low back pain
patients to actively enhance lumbar stability, using
exercises that strengthen muscle control and move-
ment.9 The CORE programme, suggested by Brill
and Couzens,10 is a lumbar stabilization exercise
programme that controls tension of the lumbar–
pelvis–hip joint to strengthen muscles, increase
endurance, and improve posture. This programme
can also be easily performed and has low direct
costs and low risk of injury.10 However, the effect
of the CORE programme on pain, active range of
motion, and proprioceptive acuity in female office
workers remains unclear. To our knowledge, most
previous studies relating to chronic low back pain
have only assessed pain at rest, although most
patients suffer from pain during daily activities.11
Therefore, evaluating movement-induced pain is
important.
Thus, the purpose of this study was to identify
the effects of the CORE programme on pain at rest,
movement-induced and secondary pain, active
range of motion, and proprioceptive acuity in
female office workers with chronic low back pain.
Materials and methods
Participants
This study is a single-blinded, randomized con-
trolled trial with three measurement time points:
baseline (pretest), after eight weeks (posttest), and
two months following completion of the exercise
programme (follow-up). Between March and
December 2011, female office workers presenting
with non-specific chronic low back pain at the par-
ticipating rehabilitation clinics located in Seoul,
South Korea were recruited. They underwent an

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Kim et al. 655
interview to record their medical history and a
physical examination by a blinded assessor. The
inclusion criteria were as follows: (1) 20–40 years
of age, (2) non-specific chronic low back pain for
more than three months, and (3) ability to move
without assistance. Patients with any history of spi-
nal or lower limb surgery, structural spinal abnor-
mality, signs of nerve compression, pregnant status,
or severe musculoskeletal disability were excluded.
In addition, participants included in the study did
not engage in regular exercise prior to the interven-
tion. All experimental procedures were conducted
in accordance with guidelines set by the local
research ethics committee. Sample size was calcu-
lated using G-Power version 3.1.3 (Informer
Technologies, Dusseldorf, Germany). The effect
size was set at 0.90, the α error at a probability of
0.05, and the power at 0.85. A minimum of 24 par-
ticipants was required in each group.
Experimental procedures and
interventions
All participants were randomly assigned to the
CORE group or the control group using random
allocation software, by an independent examiner
who was not involved in participant recruitment.12
The participants allocated to the CORE group per-
formed the CORE exercises for 30 minutes, five
times per week, for eight weeks, in addition to the
standard treatment of 20 minute transcutaneous
electrical nerve stimulation and 15 minute hot-pack
treatment, while the control group received only
the standard treatment.
Details of the eight-week CORE exercise pro-
gramme are described in Appendix 1, available
online. To assure reliability of the intervention, two
trained physical therapists instructed the partici-
pants how to perform the CORE programme exer-
cises; they ensured that the CORE group performed
the exercises appropriately, with sufficient abdomi-
nal muscle contraction. The core concept of the
programme is recruiting the abdominal muscles in
the most effective way. The CORE programme
exercises were divided into three categories (warm-
up, conditioning, and cool-down) and consisted of
14 exercises in total. The programme emphasized
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isometric movement of core muscles, including
internal/external oblique, transversus abdominis,
lumbar multifidus, rectus abdominis, and erector
spinae muscles. Participants were instructed to
carry out slow and controlled movements, to pay
attention to their breathing as they started each
exercise, and to keep breathing during each exer-
cise. Participants in the CORE group were required
to carry out the exercises at home on a daily basis
and to record their participation in a daily log to
monitor compliance. For the full programme, daily
practice was calculated as the proportion between
the self-reported mean time and the prescribed time
of exercise in a day to know the compliance rate.
Additionally, the same two physical therapists
monitored patient progress during rehabilitation
centre visits and made weekly phone calls to moti-
vate patients to continue with the CORE pro-
gramme. After eight weeks of the programme, all
participants were asked to completely stop the
exercises. Participants who received other medical
intervention, those who had personal issues that
might interfere with the study protocol, and those
who had not regularly performed the CORE pro-
gramme exercises were excluded from the study at
this stage. The purpose and process of the experi-
ment were explained to the participants, and they
voluntarily signed the informed consent form.
Outcome measurements
General characteristics, such as age, height, weight,
and duration of symptoms were assessed using a
survey method. The participants’ visual analogue
scales at rest and during movement, pain pressure
threshold, active range of motion, and repositioning
error were measured by the same blinded examiner
in order to reduce measurement error. All data were
measured in the same place, both before and after
intervention. All pretest, posttest, and follow-up
outcome measurements were evaluated by the same
examiner to ensure proper masking of patients.
To assess pain intensity at rest and during move-
ment, we used the 100-mm visual analogue scale.
Visual analogue scale at rest (resting pain) was
defined as an unpleasant feeling or pain when
patients were still. Visual analogue scale during
656 Clinical Rehabilitation 29(7)
movement (movement-induced pain) was defined
as an unpleasant feeling or pain incurred by full-
flexion of the trunk.13,14 Patients marked their sub-
jective pain intensity at rest and during movement
on a 100-mm visual analogue scale table.
Pain pressure threshold, a predictor of secondary
pain, namely chronic low back pain, was measured
using a pressure algometer (NeuroDyneMedicaco
Corp., Cambridge, MA, USA).15 The purpose of the
measurement was fully explained to participants.
The algometer was placed perpendicular to the cho-
sen lumbar sites. The examiner then applied pres-
sure on the site at a consistent rate of 1 kg/s. The
participant was asked to inform the examiner when
an unpleasant feeling or pain started, and this meas-
urement was considered the pain pressure threshold.
Two anatomical sites were used to measure pain
pressure threshold: 5 cm lateral to the L3 spinous
process (quadratus lumborum) and 5 cm lateral to
the L5 spinous process (sarcoiliac joint).16
The lumbar active range of motion was meas-
ured using DUALER PLUS inclinometers (Angle/
Level, Dejon Tool Co., Covington, OH, USA) and
was calculated as the total angle of lumbosacral
flexion and extension. To measure active range of
motion, a single inclinometer was placed over the
L1–S2 spinous processes. The inclinometer’s sen-
sor was zeroed when subjects were in a neutral
position. The angle was recorded when the highest
lumbar active range of motion was reached. This
measurement was performed three times, and the
mean value was recorded.
Proprioceptive acuity was assessed by measuring
the active positioning ability of the lumbar region.
We used the active angle reproduction method to
monitor active positioning ability.17 The patient
flexed the trunk to a predetermined target position
and then attempted to replicate the position. The par-
ticipant’s trunk was moved passively and randomly
to target angles of 20° of trunk forward flexion and
10° of trunk extension. The trunk was held for
10 seconds at the target angle and then returned to
the starting position. After maintaining the starting
position for 10 seconds, participants attempted to
replicate the target angles. Repositioning error was
calculated as the absolute difference between the
actual target position and the patients’ perceived
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target position. The absolute value of the deviation
angle was measured three times and the mean value
was calculated.
Statistical analysis
All statistics were performed using SPSS software
version 15.0 (SPSS, Chicago, IL, USA). The
Shapiro–Wilk test was used to confirm the normal-
ity of the data. Repeated measure analysis of vari-
ance was utilized to assess the visual analogue
scale scores and pain pressure threshold values at
pretest, posttest, and follow-up time points. The
Tukey multiple comparison test was used as a post-
hoc test. The independent t-test was used to com-
pare differences in dependent variables according
to the used exercise manners between the two
groups. The level of statistical significance was set
at P < 0.05.
Results
A total of 80 patients were initially recruited, and
after the screening test, 74 eligible participants
were enrolled in the study. The reasons for exclu-
sion were pregnancy, declining attendance, and
history of spinal operation. A total of 21 partici-
pants were excluded at eight weeks (posttest),
giving an attrition rate of more than 25%. The rea-
sons for exclusion were: receiving other medical
interventions, personal issues, surgery, or preg-
nancy. Figure 1 demonstrates progress through
this study.
The general characteristics of the patients are
shown in Table 1. There were no significant differ-
ences in age, height, weight, or duration of chronic
low back pain between the two groups. In the
CORE group, the eight-week programme compli-
ance rate was 85.5%.
Comparisons between the groups following
intervention, using the independent t-test, demon-
strated significant differences favouring the CORE
group with regard to pain at rest and during move-
ment, pressure pain threshold, active range of
motion, and proprioception (all P < 0.001). In the
analysis of changes in measured parameters over
time, using repeated-measure analysis of variance,
Kim et al. 657

Figure 1.  Flow diagram of this study.

AROM: active range of motion; TENS: transcutaneous electrical nerve stimulation; PPT: pain pressure threshold; VAS: visual
analogue scale.

significant differences were seen in the CORE
group regarding pain at rest (F = 141.487,
P < 0.001), pain during movement (F = 129.550,
P < 0.001), pressure pain threshold in the quadra-
tus lumborum (F = 32.205, P < 0.001) and the sac-
roiliac joint (F = 23.029, P < 0.001), and active
range of motion of trunk flexion (F = 19.992,
P < 0.001). There were no significant changes
noted in the control group. These results are pre-
sented in Table 2.
Table 3 shows the results of correlation analyses
performed in the CORE group and the control
group. Using Pearson’s correlation coefficients,
movement-induced pain was found to be most
closely correlated with proprioception at 20° flex-
ion, and decrease in the active range of motion of

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658 Clinical Rehabilitation 29(7)
Table 1.  General characteristics of the participants.
CORE group (n = 27)
Age (years) 29.7 ±3.9
Height (cm) 161.3 ±6.2
Weight (kg) 56.6 ±7.1
Duration (months) 9.7 ±3.0
Values are expressed as mean ±SD.
trunk flexion was most closely correlated with
movement-induced pain. Active range of motion of
trunk extension and proprioception at 10° exten-
sion were closely correlated with pain on move-
ment (Table 3).
Discussion
In female office workers with chronic low back
pain, we found that the CORE programme effec-
tively decreased pain at rest and movement-induced
and secondary pain. In addition, active range of
motion and proprioception improved after using
the programme. These effects were maintained for
two months following the intervention. These
results suggest that the CORE programme may
have positive effects on chronic low back pain in
female office workers.
Pain and loss of flexibility are the main symp-
toms caused by chronic low back pain; therefore,
these assessments are important indices for deter-
mining treatment efficacy. Visual analogue scale
scores are used for measuring various parameters.18
However, there is limited published evidence on
chronic low back pain available to guide research-
ers or clinicians on how to separately determine
pain at rest and pain during movement. Accordingly,
our study separately measured both pain at rest and
movement-induced pain. Our results found that the
group carrying out CORE exercises showed a sig-
nificant decrease in both pain at rest and movement-
induced pain compared with the control group. This
is similar to the results of previous studies. Goldby
et al. reported pain reduction in chronic low back
pain patients after 10 weeks of specific spinal stabi-
lization exercises.19 Koumantakis et al. also demon-
strated significant low back pain reduction that was
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Control group (n = 26) X2/t p
28.6 ±3.2 1.077 0.287
162.8 ±7.2 0.828 0.412
54.3 ±7.6 1.148 0.256
9.6 ±3.3 0.189 0.851
maintained three months after the use of stabiliza-
tion exercise.20 Typically, patients learn to recruit
deep spinal muscles by reducing undesirable hyper-
activity of other muscles during the performance of
specific stabilization exercises.21 Moreover, trunk
stability exercise programmes restore coordination
of the trunk muscles by improving the control of the
lumbar spine and pelvis.22 The CORE programme
used in our study maintained lumbar stability by
controlling tension of the lumbopelvic–hip joint
and also improved trunk coordination and posture.
These results are similar to the findings of the two
aforementioned studies that showed that exercise
maintains pain reduction and motor function
improvement from two months to two years by
increasing lumbar stability.
Compared with the control group, the CORE
group showed significantly higher scores for the
pressure pain threshold. This result is consistent
with that of Kumar’s study, in which the increase in
the pressure pain threshold was statistically signifi-
cant after stabilization exercises had been carried
out by patients with chronic low back pain.23 We
hypothesize that an association exists between an
increased pressure pain threshold and reduced back
muscle spasm. Back muscle spasm, from which
secondary pain originates, is a clinical feature of
chronic low back pain.24 This phenomenon
increases sensitivity to mechanical stimuli.25 In
addition, patients with chronic low back pain suffer
from muscle weakness in the lumbar spine.26
According to the biomechanical model theory,
weak muscles cause mechanical irritation to the
lumbar spine, which stimulates pain-sensitive struc-
tures, resulting in pain.27,28 Furthermore, continued
stimulation of pain-sensitive structures is the main
cause of maladaptive central sensitization and
Kim et al. 659

Table 2.  Changes in the visual analogue scale scores, pain pressure threshold, active range of motion, and
proprioception.

CORE group Control group t p

(n = 27) (n = 26)
Visual analogue Pretest 56.1 ±7.9 54.9 ±9.8 0.502 0.618
scale at rest (mm) Posttest 20.6 ±8.1a 49.1 ±11.1  
Follow-up 26.7 ±8.9a 52.6 ±10.2  
Difference (pre–post) 35.6 ±5.9b 5.8 ±5.2 19.361 <0.001
Difference (pre–follow-up) 29.5 ±8.5b 2.4 ±6.0 13.418 <0.001
Visual analogue Pretest 70.1 ±3.9 68.3 ±8.6 0.782 0.438
scale during Posttest 30.7 ±9.0a 63.0 ±10.5  
movement (mm) Follow-up 41.0 ±10.5a 65.7 ±9.1  
Difference (pre–post) 39.4 ±9.1b 5.3 ±6.1 15.897 <0.001
Difference (pre–follow-up) 29.1 ±11.6b 2.7 ±5.8 10.468 <0.001
Pain pressure Pretest 5.0 ±1.0 4.9 ±1.0 0.518 0.607
threshold in Posttest 7.2 ±1.1a 5.3 ±1.1  
quadratus Follow-up 6.3 ±1.0a 5.0 ±1.1  
lumborum (kg/cm2) Difference (pre–post) 2.2 ±0.7b 0.4 ±0.4 10.561 <0.001
Difference (pre–follow-up) 1.3 ±0.6b 0.1 ±0.4 9.356 <0.001
Pain pressure Pretest 4.7 ±1.1 4.6 ±1.0 0.463 0.645
threshold in Posttest 6.7 ±1.1a 4.9 ±1.1  
sarcoiliac joint (kg/ Follow-up 5.9 ±1.1a 4.7 ±1.0  
cm2) Difference (pre–post) 2.0 ±0.7b 0.3 ±0.5 10.434 <0.001
Difference (pre–follow-up) 1.2 ±0.6b 0.1 ±0.4 7.769 <0.001
Active range of Pretest 68.3 ±19.7 67.3 ±20.0 0.181 0.857
motion of trunk Posttest 99.1 ±17.5a 71.1 ±19.7  
flexion (°) Follow-up 86.8 ±16.7a 69.6 ±19.0  
Difference (pre–post) 30.8 ±14.3b 3.7 ±5.9 8.941 <0.001
Difference (pre–follow-up) 18.5 ±11.4b 2.2 ±8.1 5.943 <0.001
Active range of Pretest 14.8 ±6.5 14.7 ±8.1 0.065 0.949
motion of trunk Posttest 21.4 ±4.9a 16.7 ±7.7  
extention (°) Follow-up 17.9 ±5.7 15.4 ±9.8  
Difference (pre–post) 6.6 ±2.5b 2.0 ±3.2 5.665 <0.001
Difference (pre–follow-up) 3.0 ±1.8 0.7 ±5.9 1.962 0.055
Proprioception at Pretest 8.1±0.5 7.8 ±0.5 0.476 0.636
20° flexion Posttest 3.9 ±0.3a 6.8 ±0.4  
Follow-up 6.3 ±1.0a 7.1 ±0.6  
Difference (pre–post) 4.3 ±2.4b 1.1 ±1.5 5.894 <0.001
Difference (pre–follow-up) 3.2 ±2.1b 0.7 ±2.0 4.525 <0.001
Proprioception at Pretest 6.9 ±0.4 6.7 ±0.4 0.472 0.639
10° extension Posttest 3.9 ±0.3a 5.4 ±0.3  
Follow-up 4.8 ±0.2a 5.8 ±0.3  
Difference (pre–post) 3.1 ±2.0b 1.3 ±1.5 3.650 0.001
Difference (pre–follow-up) 2.1 ±2.0b 0.8 ±1.8 2.450 0.018

Values are expressed as mean ± SD.

aIndicates a significance difference within the group compared with that at baseline.
bIndicates a significance difference compared with the value of the control group at the corresponding time.

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660 Clinical Rehabilitation 29(7)
Table 3.  Pearson correlation coefficients between movement-induced pain and active range of motion/
proprioception.
VAS during movement vs. AROM at flexion
VAS during movement vs. AROM at extension
VAS during movement vs. proprioception at 20° flexion
VAS during movement vs. proprioception at 10° extension
VAS: visual analogue scale; AROM: active range of motion.
chronic pain.29 The vicious cycle of muscular
spasms owing to pain, and intensification of the
pain owing to these spasms, is the currently accepted
mechanism of chronic low back pain.30 We believe
that the use of our CORE programme normalized
the function of weak muscles, which, in turn,
improved support and control of the spine and pel-
vis, thereby alleviating mechanical irritation, pain,
and muscle spasm in the low back region.
This study also measured lumbar active range of
motion and trunk proprioception. These outcomes
in the CORE group improved significantly follow-
ing intervention. This is similar to the result of
Lewis’ study in which the range of motion of
patients with low back pain increased after the use
of stabilization exercises for eight weeks.31 The
results of this study were attributable to an increased
degree of spinal mobility caused by relieving lum-
bar muscular tension through the CORE pro-
gramme. As mentioned earlier, we believe that the
increase in the pressure pain threshold seen in
patients in the CORE group is owing to relief of
back muscle spasms, and the improvement in active
range of motion is related to the reduction of pain.
In addition, when we determined the correlation
between movement-induced pain and active range
of motion at flexion and extension, we found a sig-
nificantly negative correlation (Table 3). These
results suggest that reduction of movement-induced
pain has an important role in improvement of active
range of motion. We also found a negative correla-
tion between movement-induced pain and proprio-
ception (Table 3). These outcomes support the
results of previous studies in which patients with
low back pain exhibited proprioceptive impair-
ment.4 Our results also indicate that low back pain
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r p
−0.749 <0.001
−0.548 <0.001
−0.833 <0.001
−0.676 <0.001
plays an important role in changes in trunk proprio-
ception and that the alleviation of low back pain has
a positive influence on proprioception.
As previous studies have stated, therapeutic
exercises, such as core stabilization, spinal stabili-
zation, or segmental stabilization exercise, have a
positive effect on the reduction of low back
pain.19,20,31–33 .However, it is difficult to directly
compare our study with previous reports because
of differences in experimental design parameters,
including participant selection and age, causes or
duration of low back pain, outcome measurements,
intervention methods, sessions or duration of inter-
vention, and the degree of baseline pain measured
in subjects. A randomized study by Lee et al.,32
which included similar subjects and used the same
intervention period and outcome measurements as
our study, found that 50 minutes of Pilates exercise
for eight weeks (24 sessions) resulted in a decrease
of approximately 45% in low back pain in busi-
nesswomen. Furthermore, You et al. found that
40 minutes of novel core stabilization exercises,
performed three times per week, for eight week (24
sessions), decreased low back pain by approxi-
mately 30%.33 However, unlike these previous
studies, our 30-minute CORE programme, consist-
ing of 40 sessions, decreased low back pain by
63%. Based on this outcome, we suggest that an
increased number of sessions during the same
intervention period may have a greater beneficial
effect on reduction of low back pain than the exer-
cise session duration.
This study has certain limitations. First, we
chose a group of relatively healthy young women
who worked in offices. Second, the sample size
was small. Therefore, our findings cannot be
Kim et al. 661
generalized to other spinal pathologies. Third,
although we carried out a two-month follow-up
after the intervention ended, the follow-up period
was too short to draw conclusions regarding a sus-
tained positive response. Accordingly, additional
high-quality studies, with larger sample sizes and a
longer study period, are needed to assess the long-
term effects of the CORE programme on the treat-
ment of chronic low back pain.
Clinical messages
•• The CORE programme effectively
reduces pain at rest and movement-
induced and secondary pain, and this
programme improves the active range of
motion and proprioception in female
office workers with chronic low back
pain.
•• Pain reduction and proprioception were
maintained for two months following the
CORE programme intervention.
Acknowledgement
We would like to thank all participants for their will-
ingness to participate in this study. In addition, we
would like to thank Tae Sung In, Sun Hyun Lee, Sung
Jin Kim, and Mun Chul Ahn for their help in recruit-
ing subjects and their assistance with measurements.
Contributors
Kim TH, Kim EH, and Cho HY designed and planned
this experiment. Kim TH and Kim EH collected data and
monitored study process. Cho HY managed and ana-
lysed data. All three authors helped to draft and approve
the manuscript.
Conflict of interest
The authors in this study declare that there are no con-
flicts of interest.
Funding
This research received no specific grant from any fund-
ing agency in the public, commercial, or not-for-profit
sectors.
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