Physiotherapy Theory and Practice

An International Journal of Physiotherapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: http://www.tandfonline.com/loi/iptp20

Does core stability exercise improve lumbopelvic

stability (through endurance tests) more than
general exercise in chronic low back pain? A quasi-
randomized controlled trial

Mohammad Bagher Shamsi PhD, PT, Mandana Rezaei PhD, PT, Mehdi
Zamanlou MSc, PT, Mehdi Sadeghi MSc, PT & Mohammad Reza Pourahmadi
MSc, PT

To cite this article: Mohammad Bagher Shamsi PhD, PT, Mandana Rezaei PhD, PT, Mehdi
Zamanlou MSc, PT, Mehdi Sadeghi MSc, PT & Mohammad Reza Pourahmadi MSc, PT (2016):
Does core stability exercise improve lumbopelvic stability (through endurance tests) more than
general exercise in chronic low back pain? A quasi-randomized controlled trial, Physiotherapy
Theory and Practice

To link to this article: http://dx.doi.org/10.3109/09593985.2015.1117550

Published online: 11 Feb 2016.

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 PHYSIOTHERAPY THEORY AND PRACTICE
http://dx.doi.org/10.3109/09593985.2015.1117550

RESEARCH REPORT

Does core stability exercise improve lumbopelvic stability (through endurance

tests) more than general exercise in chronic low back pain? A quasi-randomized
controlled trial
Mohammad Bagher Shamsi, PhD, PTa, Mandana Rezaei, PhD, PTb, Mehdi Zamanlou, MSc, PTc, Mehdi Sadeghi,
MSc, PTd, and Mohammad Reza Pourahmadi, MSc, PTc
a
Kermanshah University of Medical Sciences, Kermanshah, Iran; bPhysiotherapy Department, School of Rehabilitation, Tabriz University of
Medical Sciences, Tabriz, Iran; cSchool of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran; dPhysical Therapy
Department, School of Rehabilitation Sciences, Tehran University of Medical Sciences, Tehran, Iran
Downloaded by [Flinders University of South Australia] at 08:30 15 February 2016

ABSTRACT ARTICLE HISTORY

Introduction: The aim was to compare core stability and general exercises (GEs) in chronic low Received 8 October 2014
back pain (LBP) patients based on lumbopelvic stability (LPS) assessment through three endur- Revised 24 June 2015
Accepted 26 June 2015
ance core stability tests. There is a controversy about preference of core stability exercise (CSE)
over other types of exercise for chronic LBP. Studies which have compared these exercises used KEYWORDS
other outcomes than those related to LPS. As it is claimed that CSE enhances back stability, Core stability exercise;
endurance tests for LPS were used. Materials and Methods: A 16-session CSE program and a GE endurance test; general
program with the same duration were conducted for two groups of participants. Frequency of exercise; low back pain
interventions for both groups was three times a week. Forty-three people (aged 18–60 years) with
chronic non-specific LBP were alternately allocated to core stability (n = 22) or GE group (n = 21)
when admitted. The primary outcomes were three endurance core stability tests including: (1)
trunk flexor; (2) trunk extensor; and (3) side bridge tests. Secondary outcomes were disability and
pain. Measurements were taken at baseline and the end of the intervention. Results: After the
intervention, test times increased and disability and pain decreased within groups. There was no
significant difference between two groups in increasing test times (p = 0.23 to p = 0.36) or
decreasing disability (p = 0.16) and pain (p = 0.73). Conclusions: CSE is not more effective than GE
for improving endurance core stability tests and reducing disability and pain in chronic non-
specific LBP patients.

Introduction CSE is fundamentally based on the idea that stability

and control of the spine are altered in people with LBP
The vast majority of low back pain (LBP) patients (up
(Costa et al, 2009). The re-education of co-activation
to 90%) are named non-specific LBP, with their pain
pattern in abdominal and back muscles is the aim of
not due to any specific or underlying disease which can
this exercise. The founders of CSE believe that LBP
be found (van Tulder and Koes, 2007). Non-specific
reduces control and coordination of the trunk muscles
LBP is usually classified according to its duration as
that affect the control of movement and stability of the
acute (less than 6 weeks), sub-acute (between 6 weeks
spine (Macedo et al, 2008). It is believed that CSE could
and 3 months), or chronic (longer than 3 months) LBP
correct the disturbed motor control pattern in local
(Refshauge and Maher, 2006). Most clinical practice
back muscles, control spinal motion, and subsequently
guidelines prescribe exercise for chronic low back
retrain optimal movement patterns (Bystrom,
pain (CLBP) treatment (Costa et al, 2009). However,
Rasmussen-Barr, and Grooten, 2013). Isolated and
there is little evidence that a particular type of exercise
voluntary contraction of local trunk muscles in low-
is any better than another (van Tulder, Malmivaara,
load exercises is assumed to restore the deficits
Esmail, and Koes, 2000). A common component of
(Vasseljen, Unsgaard-Tondel, Westad, and Mork,
exercise programs for CLBP is strengthening trunk
2012). The main point of CSE is initial low-level iso-
muscles (Liddle, Baxter, and Gracey, 2004). In recent
metric contraction of trunk stabilizing muscles (multi-
years, core stability exercise (CSE) or motor control
fidus, transversus abdominis, internal oblique) and
exercise has been considered as a treatment for LBP.

CONTACT Mehdi Sadeghi, MSc, PT mehdi.sadeghi61@gmail.com Physical Therapy Department, School of Rehabilitation Sciences, Tehran University
of Medical Sciences, Pich-e- Shemiran, Enghelab Ave., P.O. Box 113635-1683, Tehran 1148965141, Iran. Tel: +98 21 7753 3939. Fax: +98 21 7753 4133.
© 2016 Taylor & Francis
 2 M. B. SHAMSI ET AL.
progressive integration into functional tasks
(Richardson, Hodges, and Hides, 2004).
It is not agreed that CSE is preferable to general
exercise (GE) or other therapies in treatment of
CLBP. Some systematic reviews state that CSE is more
effective than general practitioner care, but not other
types of physical therapy (Ferreira et al, 2007b; Macedo,
Maher, Latimer, and McAuley, 2009; Rackwitz et al,
2006). CSE has been demonstrated as superior to GE
in the short term in some articles (Wang et al, 2012);
however, other studies indicate that both types of exer-
cise have equal effects. In these studies, it is suggested
that improvements are related to the positive effects
that physical exercise may have on the patients rather
Downloaded by [Flinders University of South Australia] at 08:30 15 February 2016
than on improvement in spinal stability (Lederman,
2010). As good evidence exists regarding the benefits
of exercise in CLBP (Hayden, Van Tulder, and
Tomlinson, 2005; Henchoz and So, 2008), GE was
chosen as a control for CSE.
Lumbopelvic stability (LPS) has been considered as
an important element of injury prevention and its
training would help recovery from injury and improve
performance (Willardson, 2007). LPS could be defined
as: “The ability of an individual to attain and then
maintain optimal body segment alignment of the spine
(lumbar and thoracic), the pelvis, and the thigh in both a
static position and during dynamic activity. Stability is
attained and maintained by passive structures and with
optimal muscle recruitment patterns, that is, without
substitution strategies” (Perrott, Pizzari, Opar, and
Cook, 2012). Five components are considered as
important for core stability: (1) strength; (2) endurance;
(3) flexibility; (4) motor control; and (5) function
(Waldhelm and Li, 2012). Strain on passive structures
of the lumbar spine and LBP may occur as a result of
poor endurance of trunk musculature. Exercise for
increasing trunk muscle endurance has been recom-
mended to increase threshold to fatigue, improve per-
formance, and reduce disability (Shankar and
Chaurasia, 2012).
Assessment of LPS is very important. Several tests
and measurements are available which claim to assess
the five components of core stability. Following a thor-
ough review of the literature, Waldhelm and Li (2012)
identified and appraised 35 different tests related to five
components of core stability. Endurance tests were the
most reliable core stability-related measurements. For
reliability (ICC) of endurance tests, the authors
reported excellent (0.93–0.99) (McGill, Childs, and
Liebenson, 1999), high (0.82–0.98) (Evans, Refshauge,
and Adams, 2007), and moderate to very high (0.66–
0.96) reliability (Waldhelm and Li, 2012). Core endur-
ance tests are an assessment in which the participants
maintain an unsupported static trunk position for a
period of time. So we decided to analyze the endurance
of the anterior, posterior, and lateral muscles of the
core as an important component of core stability
using three tests of trunk flexion, trunk extension, and
right and left side bridge tests.
In a survey of the literature, no article related to
comparing CSE and other types of exercise using
endurance core stability tests was found. In five meta-
analysis articles (Astin, Pelletier, Marie, and Haskell,
2000; Ferreira et al, 2007a; Hauggaard and Persson,
2007; Macedo, Maher, Latimer, and McAuley, 2009;
Rackwitz et al, 2006; Wang et al, 2012) comparing
CSE versus other therapies on LBP patients, no stability
assessment outcome has been investigated. In these
articles, other outcome measures such as pain intensity,
quality of life, work absenteeism, and back-specific
functional status have been studied.
The aim of the present study was to compare CSE
and GE in CLBP patients based on LPS assessment
through three endurance core stability test outcomes.
Our hypothesis was that the CSE would be more effec-
tive in improving LPS than GE. In addition, the levels
of patient’s disability and pain were investigated and
compared before and after the training.
Materials and methods
Study design
The study design was quasi-randomized controlled
trial. Approval for the research was obtained from the
ethics committee of Iran University of Medical Sciences
(IUMS).
Participants
Mannion, Taimela, Muntener, and Dvorak (2001) cal-
culated the mean and standard deviation for extensor
endurance test time in CLBP participants as 123 and 57
s, respectively. Assuming that standard deviation of
times for our test would be similar to this study, to
detect a difference between groups of 50 s and for
power of 80% and significance level of p < 0.05, a target
population of 21 participants in each group was
required.
Forty eight non-specific CLBP participants were
enrolled in the present study. Inclusion criteria were:
having LBP for more than 3 months; pain intensity
from 3 to 6 in visual analog scale (VAS); and age of
18 to 60 years. Exclusion criteria were: a history of
lumbar radicular pain; and having pathology or anom-
aly in lower limbs (e.g., malignancy, inflammatory

diseases, severe osteoporosis, arthritis, or bone dis-
eases). Based on history, imaging, and clinical examina-
tion, participants were labeled as non-specific CLBP. At
time of admission, they were given an ordinal number
starting from one and were alternately allocated into
one of two treatment groups—those with odd numbers
to core stability exercise as “CSE” group and those with
even numbers to general exercise as “GE” group. At the
first session, the study was explained for all the parti-
cipants and their informed consent was obtained.
Interventions
A common component of the two programs was a
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warm-up period (eight stretching exercises and station-
ary cycling for 5 min). An eight-step exercise approach
was followed for both groups based on previous recom-
mendations (Koumantakis, Watson, and Oldham,
2005). The exercises have been previously described in
detail in our previous article (Shamsi, Sarrafzadeh, and
Jamshidi, 2015). The difficulty of exercises was
increased progressively through eight levels. In the
first session, participants were taught how to perform
the exercises. The intervention was delivered for parti-
cipants individually (not in a group). Frequency of the
intervention was three times a week (a total of 16
sessions). In each session, the participants were asked
to perform the exercises as many times as they could
with rest periods between exercise sets. The pure exer-
cise time for CSE group was 20 min and for GE was 14
min in each session. The exercise time durations were
determined based on a previous study (Danneels et al,
2001), in order to try to balance the groups with respect
to the amount of estimated total force output of the
trunk muscles targeted by the exercises. Participants
with three consecutive or five intermittent sessions of
absence were excluded. All participants were blinded
regarding group assignment and they were unaware of
the existence of two different exercise groups. An
experienced physiotherapist was assigned to manage
both groups to perform the exercises correctly in the
exact time duration.
Core stability exercise
In the CSE group, instruction was given on anatomy
and function of local back stabilizing muscles and the
way they could be activated. The first four sessions
were focused on cognition of local muscle contrac-
tion. In the next six sessions, low levels of contraction
of these muscles were administered isometrically and
in minimally loaded positions. Step by step, integra-
tion with dynamic function (activities requiring spinal
or limb movements) was prescribed by incorporation
PHYSIOTHERAPY THEORY AND PRACTICE 3
of co-contraction of the local muscles into light func-
tional tasks. In the last six sessions of the program,
functional tasks with heavier loads through exercises
similar to those performed by the participants in GE
group were introduced progressively. It was empha-
sized to the participants that the lower part of the
anterior abdominal wall below the umbilical level
needed to be “drawn in” to ensure correct activity
of the transverses abdominis muscle. Also, the bulk of
the multifidus muscle needed to be felt under the
therapist’s fingers during contraction. To do this,
the therapist’s fingers were placed on either side of
the spinous processes of lumbar vertebrae, directly
over the belly of this muscle (Richardson, Hodges,
and Hides, 2004).
General exercise
For the GE group, exercises were focused on activating
the extensor (paraspinals) and flexor (abdominals)
muscle groups. The participants were instructed how
to perform the exercises correctly by the
physiotherapist.
Outcomes
Endurance tests
Three endurance core stability tests including: (1) trunk
flexor test; (2) trunk extensor test; and (3) bilateral side
bridge tests were performed before and after the
training.
The trunk flexor test (Figure 1) was performed by
having the subject sit on a test bench. Both the knees
and hips were flexed at 90° and the feet were fixed to
the bench with a strap. The arms crossed over the chest.
At the position of 60° trunk flexion, the support of the
trunk was then removed and the participant held the
Figure 1. Trunk flexor test.
 4 M. B. SHAMSI ET AL.
position for as long as possible. The test was terminated
when the participant was no longer able to hold the
position.
For the trunk extensor test (Figure 2), the participant
was positioned in prone with the pelvis and ankles fixed
to the test bed with straps and umbilicus at the edge of
the test bench in a cantilevered fashion, while a chair at
the same height as the surface of the table supported
the trunk and upper extremities. The chair was
removed and the individual maintained a horizontal
body position for as long as possible with arms crossed
over chest. The test was ended when the subject fell
below the horizontal position and touched down on the
chair in front of him with his hands.
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The side bridge tests (Figure 3) were performed in
the side-lying position with knees extended on a test
bench. The patient was asked to lift his hip off the bed,
Figure 2. Trunk extensor test.
Figure 3. Side bridge test.
using only his feet and lower elbow for support. The
test finished when the hip returned to the bed.
Three to five minutes of rest was taken between the
tests to ensure proper recovery for more accurate test-
ing. During all tests, participants were told to maintain
the position as long as possible. They were not provided
with any clues to their scores until the end of the test.
The total time the subject was able to hold the test was
recorded using a stopwatch.
Disability and pain
Before and after the training, the Persian translated
version of the Oswestry disability questionnaire
(Mousavi et al, 2006) (0 = no disability, 100 = totally
disabled) was completed by the participants and their
pain intensity was measured by VAS (0 = no pain, 100
= pain as bad as it could be).
Statistical analysis
To compare subject’s tests holding times, disability level,
and pain intensity between the two groups, independent-
sample t-test was used at two stages: (1) at the start of the
study to confirm equality of samples and (2) after the
intervention to find if the changes in these variables
during intervention were statistically different in the
two groups. To determine whether three variables were
changed by the intervention, paired t-test was used. Effect
size for each group was calculated as the difference
between mean values before and after the intervention
divided by the standard deviation for the data. Between-
group effect size was the difference between two means
divided by a pooled standard deviation.
Results
Different phases of the trial are presented in Figure 4.
Five participants fulfilling inclusion criteria were
excluded during the study due to poor adherence and
43 participants remained (22 participants in CSE and
21 in GE group). The participants’ characteristics are
presented in Table 1. There was an age difference
between the groups (p = 0.015) with the GE group
being older. At the time of entry to the study, there
was no statistical significant difference between the
groups in test times (p = 0.42 to p = 0.69), disability
(p = 0.97), and pain (p = 0.61). Statistical analysis for
intervention participants showed a significant increase
in endurance test times (p = 0.001 to p = 0.011 for CSE
and p = 0.001 to p = 0.029 for GE group) and a decrease
in disability level (p < 0.001) and pain intensity (p <
0.001) within each group after the treatment period
(Table 2). Regarding changes in outcomes (the
 PHYSIOTHERAPY THEORY AND PRACTICE 5

Patients with low back pain screened

for eligibility (n = 70)

Excluded (n = 12)

Screened physically (n = 58)

Excluded (n = 10)

• Radicular Pain (n = 4)
• Other Exclusion Criteria (n = 6)

Measured Core Endurance Tests, disability and pain

Month 0
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(Start) Randomised (n = 48)

Lost to follow-up

Lost to follow-up Experimental Group Control Group • did not attend (n = 2)

• did not attend (n = • Core Stability • General Exercise • excessive

2) Exercise Program Program absence (n = 1)
(n = 24) (n = 24)

Month 1 Measured Core Endurance Tests, disability and pain

(End)
(n = 22) (n = 21)

Figure 4. A flow chart diagram of different phases of the study.

not demonstrate any significant difference in outcomes

Table 1. Participants’ characteristics. between the two exercise groups.
Core stability exercise General exercise
Characteristic group group
The impressive improvement in participant’s out-
Gender: comes is in agreement with other studies. Five systema-
Male 7 6 tic reviews about CSE for CLBP were found in the
Female 15 15
Age (years)/mean 39.2 (11.7) 47.9 (10.2) literature (Ferreira et al, 2007b; Hauggaard and
(SD) Persson 2007; Macedo, Maher, Latimer, and McAuley,
Height (cm)/mean 166.4 (9.1) 163.7 (8.1)
(SD) 2009; Rackwitz et al, 2006; Wang et al, 2012). Almost all
Weight (kg)/mean 70.1 (15.1) 74.3 (10.5) studies supported the positive effect of CSE on reducing
(SD)
pain and disability, but there is controversy over
whether CSE is better than other treatments and exer-
difference between before and after intervention cises. In the most recent meta-analysis article (Wang
values), no significant differences were observed et al, 2012) (searching papers from 1970 to 2007), five
between CSE and GE groups in these variables clinical trial papers fulfilled the criteria for this study,
(Table 2). The effect size due to CSE and GE and the and CSE was better than GE in pain and disability
between-group effect size for the outcomes are pre- reduction at the time of the short-term follow-up.
sented in Table 2. However, no significant differences were found
between the two groups in reducing pain after 6 and
12 months. In this review, no stability-related outcome
Discussion was investigated. In general, our result is in agreement
In this study, CSEs and GEs were compared in people with this analysis. However, some studies have reported
with chronic non-specific LBP. A program of 16 treat- better results for CSE than those of GE (Ferreira et al,
ment sessions showed significant improvement in the 2007a; O’Sullivan, Twomey, and Allison, 1997).
endurance test holding times, the disability, and the The stability of the spine can be considered to con-
pain of participants receiving either treatment but did sist of three subsystems: (1) active, (2) passive, and (3)
 6 M. B. SHAMSI ET AL.

Table 2. Results for both exercise groups.

Core stability group General exercise group
Outcome Before*** After p-Value for Effect Before After p-Value for Effect p-Value for difference Between-group
measures difference size difference size between groups effect size
Oswestry 50.5 (12.1) 32.8 (10.5) p < 0.001 1.57 50.7 37.6 (10.9) p = 0.001 1.18 p = 0.16 0.69
disability* (11.3)
Pain 51.4 (9.8) 15.1 (11.8) p < 0.001 3.35 52.9 15.1 (13.8) p < 0.001 3.24 p = 0.73 0.83
intensity* (9.0)
Trunk flexor 48.1 (37.8) 91.5 (66.6) p = 0.001 0.80 43.4 68.3 (66.0) p = 0.029 0.47 p = 0.23 0.30
test** (36.9)
Trunk 70.6 (57.1) 117.2 (60.2) p = 0.001 0.79 80.9 113.2 (52.0) p = 0.001 0.64 p = 0.33 0.30
extensor (48.6)
test**
Right side 31.4 (26.1) 42.2 (28.2) p = 0.011 0.40 25.3 41.0 (27.9) p < 001 0.62 p = 0.30 0.56
bridge (22.3)
test**
Left side 31.2 (28.1) 42.2 (28.2) p = 0.010 0.61 26.3 41.0 (27.9) p = 0.001 0.67 p = 0.36 0.93
bridge (20.8)
test**
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*Range from 0 to 100. **Test times in second. ***Mean (SD).

control. Injury or disuse can weaken the function of
each of these subsystems, and it is assumed that train-
ing of the active subsystem can restore the function
(Mills, Taunton, and Mills, 2005). Restoration of the
ability of the neuromuscular system to control and
protect the spine from injuries is the rationale for
CSE. For this purpose, CSEs are used to restore the
coordination of the trunk muscles in order to improve
control of the lumbar spine and pelvis. The aim is also
to restore the capacity (strength and endurance) of the
trunk muscles to meet the demands of control (Hodges,
2003). Although the focus of CSE is on the re-education
of the local or deep intrinsic lumbopelvic muscles, it is
suggested that most torso muscles (and not only local
ones) are important in lumbar stability and the impor-
tance of muscles depends on their activity (McGill,
2001).
Despite the rationale for CSE, some authors
(Koumantakis, Watson, and Oldham, 2005) think the
reason why improvement in CSE outcomes versus GE
was not significant in their studies may be because CSE
might best impact those LBP patients suffering from
either gross spinal instability symptoms or prominent
side-to-side differences in the size of the multifidus
muscle as compared to individuals who do not present
any signs and symptoms of clinical instability.
Although it is claimed that CSE increases spinal
stability, the non-significant difference in the results
of the two groups in our study may be due to either
lack of specificity of CSE to increase LPS, equal
advantages of GE and CSE on improving LPS, or
even low sensitivity of our tests to measure stability
changes in the two groups after the treatment in this
sample size.
There are many tests measuring core stability com-
ponents (strength, endurance, flexibility, motor control,
and function). Pressure biofeedback was introduced to
measure the ability of the abdominal muscles to actively
stabilize the lumbar spine (Jull et al, 1993). No study
was found to have compared CSE and GE through
these tests. The only related study that was found is a
clinical trial which compared superficial strengthening
(for abdominal global muscles) and CSE (Franca,
Burke, Hanada, and Marques, 2010). The “transverse
abdominis activation capacity” using a pressure bio-
feedback unit was the outcome measure. This outcome
improved more in the CSE group than in the GE group.
It is claimed (Lederman, 2010) that none of the studies
on CSE has really indicated a relationship between
improvement in LBP and spinal stabilization or core
control. Outcome measurements in these studies have
been disability, LBP episodes, pain, and health-related
quality of life (Lederman, 2010). The novelty of our
study is trying to specifically assess LPS endurance in
order to judge the effectiveness of these exercises on
CLBP.
Our endurance tests have only measured a static
appraisal of stability and they lack the ability to assess
through-range stability in dynamic tasks. However,
increase in endurance times might indicate ameliora-
tion in the active stability of the lumbar spine.
Ultrasonography can be used to provide real-time
non-invasive feedback of the contraction of deep
back muscles (Hodges, Pengel, Herbert, and

Gandevia, 2003). This technique has been recom-
mended to assist training of motor control in CSE
(Richardson, Jull, Hodges, and Hides, 1999).
Nevertheless, there is inconsistent evidence that in a
single session, feedback with ultrasonography
enhances patients’ ability to contract local spinal
muscles properly, and there is no evidence indicating
that longer term uses of real-time ultrasound feed-
back produce better contraction (Henry and
Westervelt, 2005; Teyhen et al, 2005). It has not
been assessed whether CSE with ultrasonography
results in better outcomes than without ultrasonogra-
phy. In the present trial due to technical limitations,
ultrasonography was not used and the therapist gave
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feedback to the patients by feeling the recruitment of
stabilizer muscles. It is supposed that the therapist’s
feedback could be useful as well.
Limitations
There were some limitations in this study. Since all
participants were not defined at the beginning of the
project, we could not place them in groups by random
assignment and simply based the order by referral to
physiotherapy. The participants were placed in either
group in turn, so the study design was a quasi-rando-
mized controlled trial. We could not follow-up the parti-
cipants prospectively for a period of time. The mean age
was higher in the GE than the CSE group which can be
considered as a drawback of the sampling method.
Conclusion
The present clinical trial provides evidence that both
types of training enhance LPS. However, there is no
evidence that one type of exercise is more effective than
the other. To judge the impact of different exercises on
the LPS more accurately, it is suggested that further
studies be conducted using other methods to measure
LPS such as biomechanical models, other functional
LPS tests, or the use of a pressure biofeedback unit.
The clinical implication to consider from these data is
that both exercises could be used to treat chronic LBP
patients and improve LPS with similar effects.
Acknowledgments
The authors thank Dr. Ali Amiri and his colleagues in the
physiotherapy department of Rasool Akram Hospital
(Tehran-Iran) for their cooperation, Dr. Amir Hosein
Hashemian for his statistical advice, and Dr. Bahman
Mehraban for his grammatical correction on the manuscript.
PHYSIOTHERAPY THEORY AND PRACTICE 7
Declaration of interest
The authors of this manuscript declare that there are no
conflicts of interest that could inappropriately influence the
results of this study. There are no financial or other types of
relationships with organizations or institutes which might
inappropriately bias the writing and submission of this
manuscript.
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