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Journal of Back and Musculoskeletal Rehabilitation -1 (2018) 1–6 1

DOI 10.3233/BMR-171114
IOS Press

Treatment of disability associated with

chronic non-specific low back pain using core
stabilization exercises in pakistani population
Muhammad Waseema,∗ , Hossein Karimia , Syed Amir Gilania and Danish Hassanb
a
University Institute of Physical Therapy, Faculty of Allied Health Sciences, University of Lahore, Lahore, Pakistan
b
Riphah College of Rehabilitation Sciences, Riphah International University, Islamabad, Pakistan

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Abstract.

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BACKGROUND: Chronic non-specific low back is the most common musculoskeletal complaint that significantly affects the
general population. Exercises are advocated as the main part of treatment for chronic low back pain.
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OBJECTIVE: The purpose of this study was to compare the effects of workouts of the core musculature and routine physical
therapy exercise training for the treatment of disability caused by chronic low back pain.
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METHODS: In this single-blinded, randomized, controlled trial, 120 patients with non-specific low back pain were examined in
Lahore, Pakistan. They were randomly allocated into treatment groups A and B. Group A performed core stabilization workouts
and Group B had routine physical therapy. The Oswestry Disability Index (ODI) was used to evaluate the outcome of each
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treatment. Statistical analysis was performed using SPSS v16.0 and a p-value < 0.05 was considered significant.
RESULTS: Significant reduction in disability was observed in both groups at the end of the second, fourth, and sixth week of
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treatment (p-value < 0.05). The mean reduction in disability as measured by ODI score was 39.44 ± 14.64 for Group A and
31.91 ± 12.31 for Group B.
CONCLUSION: A larger reduction in disability was observed for subjects treated with core stabilization exercises in comparison
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to those treated with routine physical therapy.

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Keywords: Chronic low back pain, disability, Oswestry Disability Index

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1 1. Introduction age groups and is the leading cause of disability in both 11

low- and high-income countries [3]. Low back pain 12

2 Low back pain has become a massive global health and the associated disability moreover have major eco- 13

3 problem, despite its apparently benign nature. It is now nomic consequences. Americans spent $35 billion on 14

4 responsible for more years lived with disability than health services for low back pain in 2010, and this fig- 15

5 any other health condition [1]. Low back pain caused ure is increasing rapidly [4,5]. 16

6 an estimated 72 million years lived with disability in Exercise is possibly the most advocated treatment 17

7 2013, 1.5 times that of major depression (ranked #2) option for chronic low back pain [6,7]. Exercise has the 18

8 and twice that of diabetes (ranked #7) [1]. In 2013, ap- potential to improve spinal mobility, muscle strength, 19

9 proximately 615 million people worldwide lived with motor coordination, spinal stabilization and general 20

10 disabling low back pain [2]. Low back pain affects all aerobic conditioning. Additionally, the costs of exer- 21

cise therapy are reasonably low and exercise providers 22

∗ Corresponding
are readily available. A Cochrane review described 23
author: Muhammad Waseem, University Insti-
tute of Physical Therapy, The University of Lahore, 1 km Defense
randomized controlled trials that determined the ef- 24

Road, Lahore, Pakistan. Tel.: +92 3008415242; E-mail: waseempt@ fectiveness of exercises for chronic non-specific low 25

gmail.com. back pain [8]. There was convincingly strong evidence 26

ISSN 1053-8127/18/$35.00
c 2018 – IOS Press and the authors. All rights reserved
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2 M. Waseem et al. / Treatment of disability associated with chronic non-specific low back pain using core stabilization exercises

Table 1
27 that exercise is as effective as other interventions for List of exercises performed under core stabilization and routine
28 treatment of chronic low back pain; however, there physical therapy exercise
29 were also contradictions. Findings from different ex- Core stabilization exercises Routine physical therapy
30 perimental trails and systematic reviews reported in the exercises
31 Cochrane Library have persuaded the available clini- 1. Pressure feedback core 1. Hamstring stretching
32 cal practice guidelines that strongly prescribe exercise exercise in supine & prone
33 as a hallmark component for the treatment of low back 2. Multifidus exercise 2. Calf stretching
3. Frontal & Side Plank exercise 3. Hip flexors stretching
34 pain [6,7,9]. 4. Pelvic floor exercises 4. Back extensors stretching
35 Various exercises for chronic low back pain has been 5. Diaphragmatic strengthening 5. Abdominal curl-up exercise in
36 prescribed including intensive dynamic back extensor exercises supine
6. Single leg standing on foam 6. Back extensors exercise in
37 exercises [10], motor control exercises [11], yoga [12]
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38 and aerobic exercises [13]. Most of the studies have 7. Tandem standing with 7. Hip extensors exercises in
39 demonstrated the effectiveness of core stability exer- perturbation in form of rapid prone
40 cise over general exercises [14–16]. These core stabil- arm movements
41 ity exercises specifically engage the muscles that are

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42 attached to the lumbar spine, pelvis and hip area. The performed by a research assistant who did not partic- 75

43 outcome measure of reduction in pain signifies only ipate in the research process any further. Both male 76

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44 general effects of the exercises [14]. Studies by Hodges and female subjects with non-specific chronic low back 77

and Richardson on people with chronic recurrent low pain, aged between 20 to 60 years, were enrolled in this

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45 78

46 back pain found delayed activity of deep core muscles study from the outpatient department of the Orthopedic 79

and Spine Institute in Johar Town, Lahore, Pakistan.

47 (transversus abdominis, multifidus) with limb move-
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48 ments therefore failing to prepare the spine for the per- Subjects presenting any red flags or systemic illnesses 81

turbation resulting from limb movement [17]. Core sta- were excluded from the study.
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49 82

50 bility programs are successful when advocated for the The patients were blinded to the treatment, the clin- 83

51 treatment of low back pain [18–20], but effectiveness icians were not. A research assistant obtained the data 84
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52 of these exercises to achieve performance benefits is from each patient at the end of the second, fourth, and 85

53 yet to be established [21,22]. The outcome measure of sixth week of treatment. Subjects in Group A were 86
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54 reduction in pain signifies only general effects of the treated with core stabilization exercises while subjects 87

55 exercises [14,23]. It is interesting to research how this in Group B (the control group) were treated with ex- 88
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56 pain reduction in chronic low back pain patients affects ercises targeting superficial muscles of the spine (Ta- 89

57 their daily functioning in social and personal sphere of ble 1). Both exercise regimens were supervised by 90
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58 life. Thus the aim of this study was to compare the ef- a physical therapist once a week. Patients in both 91

59 fects of core stabilization exercises and routine physi- groups were advised to perform their respective exer- 92
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60 cal therapy exercises in terms of mean reduction in dis- cises twice a week at home. Brochures with the de- 93

61 ability due to chronic low back pain. scription of exercises were provided to assist during 94
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practice home. A baseline treatment of therapeutic ul- 95

trasound (3 MHZ for 10 minutes at 50% intensity) [25] 96

62 2. Methods and transcutaneous electrical nerve stimulation (con- 97

tinuous mode for 10 minutes) [26] was applied to the 98

63 This was a randomized, controlled trial of subjects lumbar region for all patients (Fig. 1). 99

64 with chronic non-specific low back pain (pain not at- SPSS v 22.0 was used to analyze the data and a p- 100

65 tributed to any specific cause and duration > 12 weeks) value < 0.05 was considered statistically significant. 101

66 with 6 weeks of follow-up. A total of 120 consecutive Nonparametric tests, the Mann Whitney U-test and 102

67 patients were selected using a non-probability, purpo- Friedman ANOVA were used to analyze across and 103

68 sive sampling technique [24] and were allocated to ei- within the group changes in disability score. 104

69 ther the treatment or control group using a computer-

70 generated random number. After receiving a signed
71 consent form from all patients, a baseline assessment 3. Results 105

72 of disability due to low back pain was made using

73 the Oswestry Disability Index (ODI) prior to alloca- A total of 120 subjects were enrolled in this study, 106

74 tion. The allocation process was concealed and was of which 12 subjects discontinued (7 in Group A and 5 107
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M. Waseem et al. / Treatment of disability associated with chronic non-specific low back pain using core stabilization exercises 3

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Fig. 1. Flow sheet diagram of the research process.
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Fig. 2. Bar chart of change in ODI score across 02 groups.

Table 2
Comparison of age and weight and height between the two treatment
in Group B). Therefore, 108 subjects were evaluated at 108

groups the sixth (and final) week of treatment. Subjects in both 109

Demographic Core stabilization Routine physical P value groups were relatively similar in terms of sociodemo- 110

variables exercise group exercise group graphic variables (Table 2). Both groups had a statisti- 111

(n = 53) (n = 55) cally significant decrease in the ODI score at the end 112
Age (Years ± SD) 46.39 ± 7.43 45.50 ± 6.61 0.09 of the second, fourth, and sixth week of treatment (Ta- 113
Height (m ± SD) 1.62 ± 0.08 1.60 ± 0.08 0.04
Weight (kg ± SD) 64.03 ± 10.00 63.69 ± 9.15 0.45 ble 3). There was a statistically significant difference 114

BMI (kg/m2 ± SD) 24.15 ± 2.38 24.82 ± 3.02 0.10 in the change from the baseline pretreatment disability 115
Male/Female 35/18 36/19 0.95 score to the post-treatment disability score (at the end 116

of week 6) in both treatment groups. The reduction of 117

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4 M. Waseem et al. / Treatment of disability associated with chronic non-specific low back pain using core stabilization exercises

Table 3
Between group comparison of disability score at the second, fourth, and sixth week of treatment
Measure Group Baseline 2nd treatment 4th treatment 6th treatment Mean change P value
week week week
ODI Core stabilization EX 56.48 ± 10.1 38.21 ± 9.52 26.59 ± 9.96 17.02 ± 7.56 39.44 ± 14.64 < 0.01
Routine physical therapy Ex 57.75 ± 10.46 42.75 ± 7.39 33.91 ± 5.75 25.84 ± 6.11 31.91 ± 12.31 < 0.01

118 the ODI score was larger for Group A (39.44 ± 14.64) observed for Group 1 over Group 2, which is consistent 160

119 than for Group B (31.91 ± 12.31) (Fig. 2). The mean with the findings of our study. 161

120 difference of the ODI score across two groups was 4.54 A comparative study comparing the effects of lum- 162

121 ± 1.78, 7.31 ± 1.70, 8.82 ± 1.43 at the 2nd, 4th and 6th bar spine stability exercises, dynamic strengthening 163

122 week respectively, with p value < 0.05. Gender based exercises and Pilates on chronic low back pain reveled 164

123 analysis revealed that male subjects responded better significant favorable outcome in terms of pain, disabil- 165

124 to core stabilization exercises than female subjects, ity and lumbar range of motion in the lumbar stabiliza- 166

125 and both genders responded equally to routine physical tion group at the 10th week post-treatment compared to 167

126 therapy exercises (Tables 4 and 5). Gender-based anal- others [29]. Rehabilitation of low back pain included 168

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127 ysis revealed that the male subjects responded to core motor control exercises targeting training of local mus- 169

128 stabilization exercise with mean reduction of 42.35 ± cles and general exercises targeting global muscles. 170

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129 11.74 as compared to 32.06 ± 12.56 (p < 0.0001) for Low back pain rehabilitation should target both local 171

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130 female subjects. However, female subjects’ response to and global muscles since stability of spine and its pro- 172

131 core and routine physical therapy exercises was mean tection form excessive loads during rehabilitation pe- 173
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132 reduction of 33.81 ± 18.16 & 31.62 ± 12.24 respec- riods, depending on the exercises targeting both local 174

133 tively (p < 0.0001). and global musculature of the spine [16]. The motor 175
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control exercises have been reported to have a better 176

outcome in comparison to manual therapy, general ex- 177

4. Discussion ercise prescription, medication prescription, manipula-

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134 178

tion, analgesic injection, or education and electrother- 179

135 The main objective of this study was to compare the apy [15,30,31]. 180
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136 effectiveness of core stabilization and routine physical In-depth biomechanical analysis of the deep mus- 181

137 therapy exercise in the reduction of disability in sub- cles of the trunk has indicated that there is delayed 182
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138 jects with chronic low back pain. Statistically signifi- activation of these muscle in subjects with low back 183

139 cant decreases were found in both groups in the change pain when spinal stability is required for different dy-
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184

140 from baseline to the end of the second, fourth, and namic tasks [32,33]. Decreases in thickness and high 185

141 sixth week of treatment. There was a statistically sig- fat content were found in the multifidus muscles of low 186
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142 nificant decrease from the baseline pretreatment dis- back pain patients as compared to normal healthy sub- 187

143 ability score and the post-treatment disability score (at jects [34]. To compensate for this delay, low back pain 188
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144 the end of the sixth week) in both treatment groups. patients tend to escalate the activity of the superficial 189

145 The results of this study were moreover supported muscles to maintain spinal stability through increased 190

146 by other studies. In a similar study by Franca et al. [27] spinal stiffness [35]. Other studies have also concluded 191

147 that compared spinal stabilization exercise with super- that patients recovering from acute low back pain have 192

148 ficial strengthening exercises in subjects with low back an increased tendency to develop the same problem if 193

149 pain, a greater reduction in the ODI score was observed not treated with exercises targeting the deep muscles 194

150 with the spinal stabilization exercises in comparison of the spine [17,36]. 195

151 to strengthening exercises. In addition, a three months

152 randomized clinical trial by Inani and Selkar [28] com-
153 pared core stabilization with routine physical therapy 5. Limitations 196

154 exercises to manage 30 patients with low back pain.

155 Core stabilization exercises included the deep mus- There was no proof of patients’ compliance with ex- 197

156 cles of the spine (Group 1), while routine strengthen- ercises performed at home prescribed by the physical 198

157 ing exercises of different superficial muscles were in- therapist. Furthermore, the type of job that the partic- 199

158 cluded in the general exercises (Group 2). Significantly ipants had was not accounted for, which might have 200

159 greater improvements in disability (p = 0.0309) were mimicked the results of the study. 201
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M. Waseem et al. / Treatment of disability associated with chronic non-specific low back pain using core stabilization exercises 5

202 6. Conclusion [9] Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle 249
P, et al. Diagnosis and Treatment of Low Back Pain: A 250
Joint Clinical Practice Guideline from the American College 251
203 A prominent decrease in disability due to chronic of Physicians and the American Pain SocietyDiagnosis and 252

204 non-specific low back pain was achieved with core sta- Treatment of Low Back Pain. Ann Intern Med. 2007; 147(7): 253

205 bility exercises as compared to general physical ther- 478-91. 254

[10] Manniche C, Lundberg E, Christensen I, Bentzen L, Hessel- 255
206 apy exercises. søe G. Intensive dynamic back exercises for chronic low back 256
pain: a clinical trial. Pain. 1991; 47(1): 53-63. 257
[11] Macedo LG, Latimer J, Maher CG, Hodges PW, McAuley JH, 258
Nicholas MK, et al. Effect of motor control exercises versus 259
207 Acknowledgments graded activity in patients with chronic nonspecific low back 260
pain: a randomized controlled trial. Phys Ther. 2012; 92(3): 261

208 This study is a part of the Degree of Philosophy in 363-77. 262

[12] Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA. 263
209 Physiotherapy at The University of Lahore, Pakistan. Comparing yoga, exercise, and a self-care book for chronic 264
210 The authors are extremely grateful to all those who low back pain: a randomized, controlled trial. Ann Intern 265

211 have helped and participated in this research. Med. 2005; 143(12): 849-56. 266
[13] Sculco AD, Paup DC, Fernhall B, Sculco MJ. Effects of aer- 267

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obic exercise on low back pain patients in treatment. Spine J. 268
2001; 1(2): 95-101. 269

Conflict of interest [14] Akhtar MW, Karimi H, Gilani SA. Effectiveness of core stabi-

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212 270
lization exercises and routine exercise therapy in management 271

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of pain in chronic non-specific low back pain: A randomized 272
213 None to report. controlled clinical trial. Pak J Med Sci. 2017; 33(4): 1002. 273
[15] Brumitt J, Matheson J, Meira EP. Core stabilization exer-
fv 274
cise prescription, part 2: a systematic review of motor control 275
and general (global) exercise rehabilitation approaches for pa- 276
References
oo
214 tients with low back pain. Sports Health. 2013; 5(6): 510-3. 277
[16] Brumitt J, Matheson J, Meira EP. Core stabilization exercise 278

215 [1] Vos T, Barber RM, Bell B, Bertozzi-Villa A, Biryukov S, Bol- prescription, part I: current concepts in assessment and inter- 279
pr

216 liger I, et al. Global, regional, and national incidence, preva- vention. Sports Health. 2013; 5(6): 504-9. 280

217 lence, and years lived with disability for 301 acute and chronic [17] Hides JA, Jull GA, Richardson CA. Long-term effects of 281

218 diseases and injuries in 188 countries, 1990–2013: a system- specific stabilizing exercises for first-episode low back pain. 282
ed

219 atic analysis for the Global Burden of Disease Study 2013. Spine. 2001; 26(11): e243-e8. 283

220 The Lancet. 2015; 386(9995): 743. [18] Carter J, Beam W, McMahan S, Barr M. Effects of stability 284

[2] Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. ball training on spinal stability in those who work in sedentary 285
ct

221
222 The global burden of low back pain: estimates from the Global occupations. Med Sci Sports Exerc. 2005; 37(5): S177-S8. 286
[19] Leetun DT, Ireland ML, Willson JD, Ballantyne BT, Davis 287
rre

223 Burden of Disease 2010 study. Annals of the rheumatic dis-

224 eases. 2014: annrheumdis-2013-204428. IM. Core stability measures as risk factors for lower extremity 288

225 [3] Hoy D, Geere J-A, Davatchi F, Meggitt B, Barrero LH. A injury in athletes. Med Sci Sports Exerc. 2004; 36(6): 926-34. 289

time for action: Opportunities for preventing the growing bur- [20] Nadler SF, Malanga GA, Bartoli LA, Feinberg JH, Prybicien 290
co

226
227 den and disability from musculoskeletal conditions in low- M, DePrince M. Hip muscle imbalance and low back pain 291

228 and middle-income countries. Best Pract Res Clin Rheumatol. in athletes: influence of core strengthening. Med Sci Sports 292
Exerc. 2002; 34(1): 9-16.
un

293
229 2014; 28(3): 377-93.
230 [4] Gaskin DJ, Richard P. The economic costs of pain in the [21] Stanton R, Reaburn PR, Humphries B. The effect of short- 294

231 United States. J Pain. 2012; 13(8): 715-24. term Swiss ball training on core stability and running econ- 295

232 [5] Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, omy. J Strength Cond Res. 2004; 18(3): 522-8. 296

233 Hollingworth W, et al. Expenditures and health status among [22] Michael AT, McManus AM, Masters RS. Development and 297

234 adults with back and neck problems. Jama. 2008; 299(6): 656- validation of a core endurance intervention program: implica- 298

235 64. tions for performance in college-age rowers. J Strength Cond 299

236 [6] Burton A, Balagué F, Cardon G. COSTB13 Working group: Res. 2005; 19(3): 547. 300

237 European guidelines for the management of low back pain, [23] Paungmali A, Joseph LH, Sitilertpisan P, Pirunsan U, 301

238 chapter 2: European guidelines for prevention in low back Uthaikhup S. Lumbopelvic Core Stabilization Exercise and 302

239 pain. Workers. Eur Spine J. 2006; 15: S148-S57. Pain Modulation Among Individuals with Chronic Nonspe- 303

240 [7] Chou R, Huffman LH. Nonpharmacologic Therapies for cific Low Back Pain. Pain Practice. 2017; 17(8): 1008-14. 304

241 Acute and Chronic Low Back Pain: A Review of the Evidence [24] Elfil M, Negida A. Sampling Methods in Clinical Research; 305

242 for an American Pain Society/American College of Physi- an Educational Review. Emergency. 2017; 5(1). 306

243 cians Clinical Practice GuidelineNonpharmacologic Thera- [25] Draper DO, Mahaffey C, Kaiser D, Eggett D, Jarmin J. Ther- 307

244 pies for Acute and Chronic Low Back Pain. Ann Intern Med. mal ultrasound decreases tissue stiffness of trigger points 308

245 2007; 147(7): 492-504. in upper trapezius muscles. Physiother Theory Pract. 2010; 309

246 [8] Furlan AD, Van Tulder MW, Cherkin D, Tsukayama H, Lao 26(3): 167-72. 310

247 L, Koes BW, et al. Acupuncture and dry-needling for low [26] Deyo RA, Walsh NE, Martin DC, Schoenfeld LS, Rama- 311

248 back pain. The Cochrane Library. 2005. murthy S. A controlled trial of transcutaneous electrical nerve 312
 Galley Proof 14/09/2018; 9:55 File: bmr–1-bmr171114.tex; BOKCTP/xjm p. 6

6 M. Waseem et al. / Treatment of disability associated with chronic non-specific low back pain using core stabilization exercises

313 stimulation (TENS) and exercise for chronic low back pain. N [32] Hodges PW, Richardson CA. Delayed postural contraction of 333
314 Engl J Med. 1990; 322(23): 1627-34. transversus abdominis in low back pain associated with move- 334
315 [27] França FR, Burke TN, Hanada ES, Marques AP. Segmental ment of the lower limb. Clin Spine Surg. 1998; 11(1): 46-56. 335
316 stabilization and muscular strengthening in chronic low back [33] Hodges PW, Richardson CA. Altered trunk muscle recruit- 336
317 pain: a comparative study. Clinics. 2010; 65(10): 1013-7. ment in people with low back pain with upper limb movement 337
318 [28] Inani SB, Selkar SP. Effect of core stabilization exercises ver- at different speeds. Arch Phys Med Rehabil. 1999; 80(9): 338
319 sus conventional exercises on pain and functional status in pa- 1005-12. 339
320 tients with non-specific low back pain: a randomized clinical [34] Alaranta H, Tallroth K, Soukka A, Heliövaara M. Fat content 340
321 trial. J Back Musculoskelet Rehabil. 2013; 26(1): 37-43. of lumbar extensor muscles and low back disability: a radio- 341
322 [29] Bhadauria EA, Gurudut P. Comparative effectiveness of graphic and clinical comparison. Clin Spine Surg. 1993; 6(2): 342
323 lumbar stabilization, dynamic strengthening, and Pilates on 137-40. 343
324 chronic low back pain: randomized clinical trial. J Exerc Re- [35] van Dieën JH, Selen LP, Cholewicki J. Trunk muscle activa- 344
325 habil. 2017; 13(4): 477. tion in low-back pain patients, an analysis of the literature. J 345
326 [30] Hoppes CW, Sperier AD, Hopkins CF, Griffiths BD, Principe Electromyogr Kinesiol. 2003; 13(4): 333-51. 346
327 MF, Schnall BL, et al. The efficacy of an eight-week Core sta- [36] Richardson CA, Hodges P, Hides J. Therapeutic exercise for 347
328 bilization program on Core muscle function and endurance: a lumbopelvic stabilization: Churchill Livingstone; 2004; 271. 348
329 randomized trial. Int J Sports Phys Ther. 2016; 11(4): 507.
330 [31] Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcuta-
331 neous electrical nerve stimulation (TENS) versus placebo for

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332 chronic low-back pain. The Cochrane Library. 2008.

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