Authors:

Pedro Ángel Baena-Beato, PhD

Manuel Delgado-Fernández, PhD Exercise
Enrique G. Artero, PhD
Alejandro Robles-Fuentes, PhD
Marı́a Claudia Gatto-Cardia, BSc
Manuel Arroyo-Morales, PhD
BRIEF REPORT
Affiliations:
From the Department of Physical
Education and Sport, University of
Granada, Granada, Spain (PÁB-B,
MD-F, AR-F); Department of Exercise
Science, Arnold School of Public Disability Predictors in Chronic Low
Health, University of South Carolina,
Columbia (EGA); Department of Back Pain After Aquatic Exercise
Education, University of Almerı́a,
Almerı́a, Spain (EGA); Department of
Physiotherapy, Universidade Federal da
Paraı́ba, Paraı́ba, Brasil (MCG-C); and ABSTRACT
Department of Physiotherapy,
University of Granada, Granada, Spain Baena-Beato PÁ, Delgado-Fernández M, Artero EG, Robles-Fuentes A, Gatto-
(MA-M). Cardia MC, Arroyo-Morales M: Disability predictors in chronic low back pain after
aquatic exercise. Am J Phys Med Rehabil 2014;93:615Y623.
Correspondence: The physical and psychological factors associated with reduction of disability after
All correspondence and requests for
aquatic exercise are not well understood. Sixty participants (30 men and 30 women;
reprints should be addressed to Manuel
Delgado-Fernández, PhD, age, 50.60 [9.69] yrs; body mass index, 27.21 [5.20] kg/m2) with chronic low
Departamento de Educación Fı́sica y back pain were prospectively recruited. The 8-wk aquatic therapy program was
Deportiva, Facultad de Ciencias de la
Actividad Fı́sica y el Deporte carried out in an indoor pool sized 25  6 m, with 140-cm water depth and 30-C
Universidad de Granada, Carretera de (1-C) of water temperature, where patients exercised for 2Y5 days a week. Each
Alfacar, s/n, 18011, Granada, Spain.
aquatic exercise session lasted 55Y60 mins (10 mins of warm-up, 20Y25 mins
of aerobic exercise, 15Y20 mins of resistance exercise, and 10 mins of cool-
Disclosures:
down). Demographic information, disability (Oswestry Disability Index), back pain
Supported by a postdoctoral fellowship
from the Spanish Ministry of Education (visual analog scale), quality-of-life (Short Form 36), abdominal muscular endurance
(EX-2010-1008). (curl-up), handgrip strength, trunk flexion and hamstring length (sit and reach), resting
Financial disclosure statements have
been obtained, and no conflicts of heart rate, and body mass index were outcomes variables. Significant correlations
interest have been reported by the between change in disability and visual analog scale (at rest, flexion, and extension),
authors or by any individuals in control
curl-up and handgrip (r ranged between j0.353 and 0.582, all Ps G 0.01) were
of the content of this article.
found. Changes in pain and abdominal muscular endurance were significant pre-
dictors of change in disability after therapy.
0894-9115/14/9307-0615
American Journal of Physical Key Words: Disability, Chronic Low Back Pain, Muscle Endurance, Aquatic Exercise
Medicine & Rehabilitation
Copyright * 2014 by Lippincott
Williams & Wilkins
D isability is a complex concept covering impairments, activity limitations, and
participation restrictions, reflecting the interaction between features of a person’s
DOI: 10.1097/PHM.0000000000000123
body and features of the society in which he/she lives.1 Patients with chronic low
back pain (CLBP) experience clinical manifestations, including physical and psy-
chological symptoms that affect their health status.2 Most low back painYrelated
costs to society derive from patients’ disability, which is also the main deter-
minant of patients’ quality-of-life (QoL).3,4 Disabilities are common in patients
with CLBP,5 which is the third leading cause of chronic functional disability after
respiratory conditions and injuries.6 Therefore, treating disability is as impor-
tant as treating pain.7
Different therapeutic exercise programs have showed effectiveness to im-
prove disability,8Y10 but the results are controversial.11 The factors interacting
with physical measures of impairment in explaining disability and the relative

www.ajpmr.com Change in Disability After Aquatic Exercise 615

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 extents to which psychological and physical factors
account for improvements in outcome after ther-
apy for CLBP have rarely been examined. Mannion
et al.12 established explicative models of changes in
disability promoted by therapeutic exercise, where
changes in pain, psychological distress, and fear-
avoidance beliefs accounted for only 24% of the
changes in disability after therapy. More precise
and explicative models are needed to treat adequately
this health problem.
Disability in back pain is highly influenced by
pain, physical impairment, and psychological and
psychosocial factors.3,13 Patients with CLBP usually
report that pain is their main problem and the main
cause of their disability.3 In individuals with chronic
disabilities, pain may induce serious psychological
problems, negatively affecting QoL,14 where psy-
chological distress has been identified as one
potential pathway by which an episode of pain in-
fluences the development of persistent disabling
symptoms.15
These factors explain only a portion of how
CLBP affects disability, and other factors should
be explored. There are evidences that exercise can
decrease disability, pain, and secondary physical decon-
ditioning in patients with CLBP,16 where physical
treatments are based on the assumption that in-
creased muscle strength, aerobic capacity, and stretch-
ing are crucial for the resumption of activities and
for the reduction of disability.17,18 Previous studies
have concluded that aquatic exercise may contribute
to a decline in disability and pain and produce im-
proved psychological and psychosocial factors.8,9
Aquatic exercise is of particular interest in CLBP
because the unique properties of water reduce stress
in joints and decrease axial loading of the spine.19
Moreover, continuous limb movements against the
water resistance result in muscle strength20 and car-
diovascular benefits.21 The aquatic environment
enables the participant to perform movements that
are normally difficult or impossible on land.22 Sev-
eral studies indicate that therapeutic aquatic exer-
cise can be a safe and effective treatment modality
for patients with CLBP.9,10 There are no previous
models to explain the clinical and physical factors
involved in disability improvements after aquatic ex-
ercise programs in CLBP.
To the best of the authors’ knowledge, no pre-
vious study has investigated the association between
pain, QoL, and health-related fitness with disabil-
ity in patients with CLBP after therapy. The aim
of the study was to discover potential predictors
of improvement disability in CLBP treated with
aquatic exercise.
616 Baena-Beato et al.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
METHODS
Participants
A total of 60 sedentary adults with CLBP (30 men
and 30 women), defined as arising below the last rib
margin and above the inferior gluteus lines and
with a duration pain of greater than 12 wks, aged
50.60 (9.69) yrs, with body mass index (BMI) of
27.21 (5.20) kg/m2, volunteered to participate in
this study. Participants were recruited in Massam
Sport Center (Granada, Spain), and they received
written and oral instructions about the interven-
tion, the test protocol, and the possible risks and
benefits of the study. Written informed consent was
obtained before participation. The study was ap-
proved by the ethical committee of the University of
Granada and was performed in accordance with the
Helsinki Declaration, last modified in 2000. The
inclusion and exclusion criteria for this study ap-
pear on Table 1. The study flow of participants is
presented in Figure 1.
Treatment
The 8-wk aquatic therapy program was carried
out in an indoor pool sized 25  6 m, with 140-cm
water depth, 30-C (1-C) of water temperature, where
participants exercised for 2Y5 days a week. Each
aquatic exercise session was conducted in small
groups of 8 participants and lasted 55Y60 mins
(10 mins of warm-up, 20Y25 mins of aerobic exer-
cise, 15Y20 mins of resistance exercise, and 10 mins
of cooldown). The resistance exercises progressed
throughout the program by changing the number of
repetitions per set (volume, 3 sets per 12 repetitions
TABLE 1 Inclusion and exclusion criteria
Inclusion criteria:
-Age between 25 and 64 yrs
-Presence of self-reported low back pain for more than
12 wks23
Exclusion criteria:
-Symptoms or signs that might suggest serious med-
ical illness
-Pregnancy or recent childbirth
-Major rheumatologic, neurologic, neoplastic, or other
conditions that may prevent full participation in the
intervention
-Previous spinal surgery, inflammatory, infectious, or
malignant diseases of the vertebra
-Presence of any psychiatric disorder that might affect
the compliance and the assessment of symptoms
-Presence of severe cardiovascular disease
-Engagement in physical activity for 60 mins or longer
per week during the last 12 mos24
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 7, July 2014
FIGURE 1 Flow of participants throughout the trial.
in the first week to 3 sets per 15 repetitions in the
eighth week), by including specific resistance mate-
rials that increase the resistance offered by the water,
and by increasing the velocity of the movements.
Noodles and cuff devices were used for upper-body
and lower-body exercises, respectively. Each training
session included the following resistance exercises:
hip flexion-extension, hip abduction-adduction, arms
abduction-adduction at chest level, curl-ups, scissors
leg, and backstroke kick with water noodle under
the waist. The planning of the aerobic exercises was
increased considering the intensity (Borg scale of
6Y20, 10Y12 in the first week to 12Y15 in the eighth
week) and the volume (minutes). The aerobic exer-
cises incorporated large muscle mass and consisted
of lateral displacements, long-lever pendulumlike
movements of the extremities, forward and back-
ward jogging with arms pushing, pulling and pressing,
leaps, kicks, leg crossovers and hopping movements
focusing on traveling in multiple directions, and
bounding off the bottom of the pool. Heart rate was
assessed using the POLAR 610 heart-rate monitor
(Polar Electro OY, Finland) at different moments of
the program when patients were out of the pool.
Participants were monitored in different sessions
to assess if the intensity recommendations were
followed. At the end of each session, static stretching
www.ajpmr.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
techniques were performed for gluteus, lumbar back,
and hamstrings, as part of the cooldown. Sessions
were supervised by physical therapists with more
than 6 yrs of experience in the management of CLBP
through aquatic exercise programs.
Outcome Measures
To assess changes in different parameters after
aquatic exercise, all measurements were taken at
baseline and 24 hrs after discharge in the aquatic
exercise program.
Questionnaires
Participants were evaluated for the following
self-completed questionnaires.
Oswestry Low Back Pain
Disability Questionnaire
The Spanish version of the Oswestry low back
pain disability questionnaire26 was used. The reli-
ability and validity of this questionnaire have been
found to be acceptable,26 and the minimal clinical
change is considered to be 10%.27
Visual Analog Scale
Back pain was assessed at rest and during move-
ment of the trunk (flexion and extension) using a
Change in Disability After Aquatic Exercise 617
 visual analog scale (VAS). The reliability and validity
of VAS have been found to be acceptable,28 and the
minimal clinical change is considered to be 15 mm.29
Short Form 36 Health Survey
The Spanish version of Short Form 36 (SF-36)
is a generic instrument assessing health-related
QoL.29 It contains 36 items and yields 8 domains
(parameters). These 8 parameters can be used to
derive 2 composite scoring summaries: physical com-
posite summary (PCS SF-36, physical functioning,
physical role, bodily pain, and general health percep-
tions) and mental composite summary (MCS SF-36,
vitality, social functioning, mental health, and emo-
tional role). The SF-36 is a sensitive measure of treat-
ment success in patients with low back pain.30 Each
domain is scored on a scale from 0 (worst possible
health) to 100 (best possible health).31
Fitness Outcomes
Participants were evaluated in fitness for curl-up
test, handgrip strength, sit and reach test, and rest-
ing heart rate. BMI was also measured. All testing
sessions were conducted by the same experimented
researcher.
Curl-up Test
Abdominal muscular endurance was measured
using the curl-up test.25 The cadence for the test
was 40 beats/min, paced by a metronome. The test
was terminated when the subject was unable to main-
tain the required cadence or unable to maintain the
proper curl-up technique for 2 consecutive repe-
titions despite feedback from the researcher. The
highest number of repetitions completed while
maintaining proper form was recorded.
Handgrip Strength Test
A hand dynamometer with adjustable grip was
used (TKK 5101 Grip D; Takey, Tokyo, Japan). The
test was performed twice, and the maximum score
for each hand was recorded in kilograms. Optimal
grip was noted for each participant in the pretest
and repeated in the posttest. The sum of the scores
achieved by the left and right hands was used in
the analysis.32
Sit and Reach Test
Trunk flexion and hamstring length were de-
termined via the sit and reach test, as described by
the American College of Sport Medicine’s protocol.25
Resting Heart Rate
Participants were instructed in the procedure
of measuring their pulse rate and then were asked
618 Baena-Beato et al.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
to register resting heart rate manually at home,
from the carotid artery using a stopwatch. They re-
gistered resting heart rate in four nonconsecutive
days during pretest and posttest weeks. The mean
heart rate among the four measurements was used
as resting heart rate before and after the intervention.
Body Mass Index
Weight (kilograms) was measured using Octa-
polar bioimpedance analyses (Biospace Inbody 720;
Biospace Company, Ltd, Seoul, Korea). Biospace
Inbody Analyse has been found to be reliable.33 Height
(meters) was measured in the Frankfurt plane with
a telescopic height-measuring instrument (Type
SECA 225; range, 60Y200 cm; precision, 1 mm). BMI
was calculated (kg/m2).
Statistical Analyses
Mean and 95% confidence interval were re-
ported for continuous variables with a normal dis-
tribution. Normal distribution of data was checked
using Kolmogorov-Smirnov test. A t paired test was
carried out to show the difference between baseline
and postintervention data. Pearson and Spearman
correlation analyses were applied whenever appro-
priate. The correlation analyses were carried out
between the change (,), postdifference-predifference
at baseline (pretest) and follow-up (posttest), in the
disability (Oswestry Disability Index, ODI), back pain
(VAS at rest), PCS SF-36 and MCS SF-36, abdominal
muscular endurance (curl-up), handgrip strength,
trunk flexion and hamstring length (sit and reach),
resting heart rate, and BMI, after the physical therapy
program. The assumptions of normality, linearity,
and homoscedasticity were investigated by the re-
sidual scatterplots. Stepwise multiple regression anal-
ysis was used to explore which variables could
explain the variation in disability (dependent vari-
able). The changes in back pain, health-related QoL,
abdominal muscular endurance, handgrip strength,
trunk flexion and hamstring length, resting heart
rate, and BMI were considered independent variables.
The requirements of an independent variable to be
included in the multiple regression analysis were as
follows: (1) the correlation coefficients between the
dependent variable and the independent variables
were significant and r Q 0.25, and (2) the correla-
tion coefficients between the independent variables
were r e 0.7.34 Finally, the final model was validated
using bootstrapping. Specifically, the bootstrapping
method was carried out with repeated samples of
the same size as the original samples in replace-
ment. Two thousand replications were produced to
estimate bootstrap bias-corrected and accelerated
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 7, July 2014
confidence intervals. For statistical analyses, sig-
nificance level was set at P G 0.05. All analyses were
performed using R software (2.9.3).
RESULTS
Forty-one percent of the participants had an
educational status of unfinished studies and primary
school, and 59% had secondary school and a uni-
versity degree; 75% of the participants listed civil
status as married. Occupational status was dis-
tributed as housewife, 23%; working, 42%; retired,
22%; and unemployed, 13%. All participants were
white from Granada metropolitan area. Participants
showed moderate disability (mean [SD], 29.3 [13.4]),35
pain was from moderate to intense (mean [SD],
6.20 [2.23]),36 PCS SF-36 was low (mean [SD],
35.9 [9.89]),31 MCS SF-36 was moderate (mean
[SD], 50.2 [11.4]),31 curl-up was low (mean [SD],
12.4 [5.41]),25 handgrip test was from low to mod-
erate (mean [SD], 69.4 [20.2]),37 and sit and reach
test was very low (mean [SD], 9.15 [9.86]),25 with
BMI of overweight (mean [SD], 27.2 [5. 20])25 and
resting heart rate (mean [SD], 69.4 [8.88]).38 Table 2
shows the baseline and postintervention scores.
Correlational Analyses
Significant positive correlations between change
in disability and VAS at rest (r = 0.582, P G 0.01),
VAS at flexion (r = 0.410, P G 0.01), and VAS at
extension (r = 0.424, P G 0.01) were moderate.
Significant negative correlations were also found
between change in disability and change in curl-up
(r = j0.353, P G 0.01), and change in disability and
change in handgrip strength (r = j0.431, P G 0.01)
were moderate.
In addition, significant correlations existed among
the independent variables (j0.353 G r G 0.582; see
Table 3), but none was considered to be multicollin-
ear (defined as r 9 0.70); therefore, each one was
included in the regression analyses.
Regression Analyses
Stepwise regression analyses revealed that
changes in back pain intensity and abdominal mus-
cular endurance were independent and significant
predictors of change in disability after aquatic ex-
ercise, and when combined, they explained 48% of
the variance (see Table 4).
DISCUSSION
Current findings suggest that changes in back
pain intensity and abdominal muscular endurance
after 8 wks of aquatic exercise program have a
relevant contribution to changes in CLBP-related
disability.
Disability related to CLBP may be caused by
pain, physical impairment, psychological distress,
and psychosocial factors.3,39 This study is the first to
specifically examine disability determinants related
to pain intensity and abdominal muscular endurance,
after a treatment based on aquatic exercise program.
Because rehabilitation strategies are focused on re-
ducing pain and clinical repercussions from CLBP,
particularly disability, understanding potential deter-
minants for reduced disability may assist in the reha-
bilitation process in these patients.
We observed that ODI and back pain (VAS)
decreased in the participants beyond the minimal
clinical change accepted in patients with low back
pain,27 where they improved their levels from baseline

TABLE 2 Effects of an 8-wk aquatic therapy program in adults with CLBP

Pretest, Posttest, Minimum and Maximum
Mean T SEM Mean T SEM P Values in Healthy Adults
ODI, scores of 0Y100 29.3 T 13.4 16.8 T 11.3 G0.0001 Minimal functional limitation G 20
to maximal functional limitation 9 8035
VAS rest, cm, 0Y10 6.20 T 2.23 2.65 T 2.11 G0.0001 Mild to moderate pain G 4 to severe 9 636
VAS flex, cm, 0Y10 6.30 T 2.32 2.43 T 2.14 G0.0001
VAS ext, cm, 0Y10 5.18 T 3.05 1.85 T 2.15 G0.0001
PCS SF-36, scores of 0Y100 35.9 T 9.89 44.9 T 9.08 G0.0001 Lowest possible score of 0 to highest
possible score of 10031
MCS SF-36, scores of 0Y100 50.2 T 11.4 50.1 T 9.56 0.932
Curl-up, no. repetitions 12.4 T 5.41 20.8 T 5.83 G0.0001 Need improvement, 5, to excellent, 2525
HS, kg 69.4 T 20.2 75.1 T 20.5 G0.0001 Very poor, e59, to excellent, 910737
SR, cm 9.15 T 9.86 13.5 T 9.54 G0.0001 Need improvement, 17, to excellent, 3525
HRR, ppm 69.4 T 8.88 64.8 T 7.78 G0.0001 Bradycardia (G40Y45), tachycardia (990Y95)38
BMI, kg/m2 27.2 T 5.20 26.8 T 5.01 G0.0001 Normal, 18.5Y24.9, to overweight, 25.0Y29.925
HRR, heart rate at rest; HS, handgrip strength; SR, sit and reach; VAS ext, VAS at extension; VAS flex, VAS at flexion; VAS rest,
VAS at rest.

www.ajpmr.com Change in Disability After Aquatic Exercise 619

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 TABLE 3 Pearson product-moment correlation matrix for study variable
, PCS , VAS , VAS , VAS
, ODI SF-36 rest flex ext , HS , SR , BMI , HRR , Curl
, ODI 1.00 V V V V V V V V V
, PCS SF-36 j0.009 1.00 V V V V V V V V
, VAS rest 0.582a j0.164 1.00 V V V V V V V
, VAS flex 0.410a j0.446a 0.625a 1.00 V V V V V V
, VAS ext 0.424a j0.076 0.655a 0.570a 1.00 V V V V V
, HS j0.431a 0.314 j0.355 j0.373a j0.385a
b a
1.00 V V V V
, SR j0.193 0.215 j0.141 j0.221a j0.015 0.348a 1.00 V V V
, BMI 0.058 0.114 0.244 0.072 0.199 0.095 j0.125 1.00 V V
, HRR 0.242 j0.018 0.223 0.305b 0.150 j0.481a j0.176 j0.098 1.00 V
, curl j0.353a b
0.023 j0.039 j0.314 j0.153 0.288b 0.206 0.182 j0.349a 1.00
a
P G 0.01. bP G 0.05.
,, change between postdifference-predifference at baseline (pretest) and follow-up (posttest); HRR, heart rate at rest; HS,
handgrip strength; SR, sit and reach; VAS ext, VAS at extension; VAS flex, VAS at flexion; VAS rest, VAS at rest.

in 43% in ODI, 57% in VAS at rest, 61% in VAS in
flexion, and 64% in VAS in extension. The authors
also observed an increase of 20% in the physical
domains of health-related QoL (PCS SF36), and MCS
SF36 showed a very slight decrease of less than 1%,
but the differences before and after the intervention
were not statistically significant (see Table 2). These
changes were accompanied by improvements in fit-
ness and BMI, where participants obtained improve-
ments of 68% in the curl-up test (moved from low to
good level),25 8% in the handgrip test (moved from
low to medium level), 47% in the sit and reach test,25
6.6% in the heart rate at rest,38 and 2% in BMI keep-
ing in overweight.25
To the best of the authors’ knowledge, only one
study has investigated predictor’s variables in dis-
ability after therapy in patients with CLBP.12 Mannion
et al.12 (2001) also reported a model where pain,
psychological distress, and fear-avoidance belief
accounted for 24% of the variance in disability after
treatment. The study’s model was able to explain in
total 48% of the variability in disability after ther-
apy in patients with CLBP, where a reduction of
pain intensity combined with an improvement in
abdominal muscular endurance could contribute
to reducing disability.
Patients with CLBP usually report that pain is
their main problem and the main cause of their
disability.3 In the present study, change in pain is
the variable with the largest contribution (33%) to
the total explained variance; this was reflected by
higher back pain intensity in patients with CLBP
reporting greater disability. These results are in
accordance with previous studies using multivariate
analysis to predict disability, which have shown that
pain normally explains the greatest or second
greatest proportion of the variance.12,13,40,41 The
relationship between disability and pain is bidirec-
tional and a complex process, as disability is a
symptom of pain resulting in loss of function. Back
pain may lead to disability through its effects on
physical impairment42 and psychological distress.15
It is often assumed that patients who feel more
disabled and thus report more daily life restrictions
caused by pain intensity43 will be those who are less
physically active in CLBP.44 This is reflected in
treatments recommended for CLBP, which typically
promote increased physical activity to aid recovery
and reduce pain intensity and disability.
Abdominal muscle endurance was a significant
and relative new determinant of disability in the
present study (15% to the total explained variance
in disability after therapy) and was one of the few
physical factors that retained its importance when
considered in combination with the pain. One im-
portant risk factor for low back pain is weakness of
abdominal muscles,45,46 and strengthening of these
is often associated with significant improvements
of CLBP as well as with decreased functional
disability.47Y49 Abdominal muscular endurance is
suggested to be reduced in patients with CLBP,50
because weakened abdominal muscles cannot main-
tain normal inclination of the pelvis, which increases
lordosis of the lumbar spine,51 and an increase of
lumbar lordosis has shown to be inversely correlated
with pain.52 Changes in muscle activity have been
observed in experimental53 and clinical studies54 in-
duced by pain, where reflex inhibition is suggested to
play a role.55 The role of muscular strength in the
performance of activities of daily living (sitting,
standing, lifting, or rolling over in bed), as well as in
the prevention of chronic disease, is increasingly

620 Baena-Beato et al. Am. J. Phys. Med. Rehabil. & Vol. 93, No. 7, July 2014

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 being recognized.56,57 There is an association be-

r2 (%)

A, regression coefficient; ,, change between postdifference-predifference at baseline (pretest) and follow-up (posttest); r 2, variability of disability explained by the respective predictor in percent; VAS rest, VAS
32.7
15.3
tween abdominal muscle endurance and disability,
where qualitative changes in posture58 and move-
ment can occur dramatically and spontaneously

G0.0001
G0.0001
0.190 because of gradual changes in parameters of ab-
P

dominal muscular endurance, resulting in some

degree of disability hindering the patient to per-
1.326
6.241
j3.939

form activities of daily living.59

t

The authors recognize some limitations of the

study. They included a relatively small sample size
Standardized Coefficients, A

(n = 60). However, because of the small sample size,

the number of independent variables entered in the
regression analysis was limited to reduce the like-
0.597
j0.376

lihood of a type II error. Other relevant outcomes

such as lumbar musculature endurance levels should
be examined in future research to provide more
global information about the relationship between
TABLE 4 Summary of stepwise regression analyses to determine predictors of improvement in disability (r 2 = 48%)

physical condition and disability. Long-term out-

comes were not performed in these subjects so it
Bootstrap, A

cannot be determined whether the effect of the treat-

3.335
2.256
j0.935

ment can be maintained over time. Another limi-

tation may be that group interaction or attention from
the therapist gave positive feeling to the participants.
Bootstrap BCA, 95% CI

j1.413 to j0.552

CONCLUSIONS
j1.141 to 7.850
1.596Y2.945

Changes in pain intensity and abdominal mus-

cular endurance were significant predictors of change
in disability in patients with CLBP after therapy.
Aquatic exercise decreases levels of disability and
back pain, increases QoL, and improves BMI and
fitness in sedentary adults with CLBP. Therapists
j1.414 to j0.461
j1.712 to 8.430
95% CI for A

working with patients with CLBP should take into

1.537Y2.989

account these relationships to improve the man-

agement of CLBP-related disability.

ACKNOWLEDGMENTS
The authors thank the Massam Sport Center
Unstandardized Coefficients, A

(Granada, Spain) for allowing them to use the facili-

ties and all the participants for their collaboration.
3.359
2.263
j0.937

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