Clinical Trial/Experimental Study

Medicine ®

OPEN

The effect of lumbar stabilization and walking

exercises on chronic low back pain
A randomized controlled trial
a b b b
Jee Hyun Suh, MD , Hayoung Kim, BS , Gwang Pyo Jung, MD , Jin Young Ko, MD , Ju Seok Ryu, MD,
∗
PhDb,
Abstract
Background: Various exercises have been proposed to mitigate chronic low back pain (LBP). However, to date, no one particular
exercise has been shown to be superior. Hence, the aim of this study was to compare the efficiency between 2 exercises: the
individualized graded lumbar stabilization exercise (IGLSE) and walking exercise (WE).
Methods: A randomized controlled trial was conducted in 48 participants with chronic LBP. After screening, participants were
randomized to 1 of 4 groups: flexibility exercise, WE, stabilization exercise (SE), and stabilization with WE (SWE) groups.
Participants underwent each exercise for 6 weeks. The primary outcome was visual analog scale (VAS) of LBP during rest and
physical activity. Secondary outcomes were as follows: VAS of radiating pain measured during rest and physical activity; frequency
of medication use (number of times/day); Oswestry disability index; Beck depression inventory; endurances of specific posture; and
strength of lumbar extensor muscles.
Results: LBP during physical activity was significantly decreased in all 4 groups. Exercise frequency was significantly increased in
the SE and WE groups; exercise time was significantly increased in the SE group. The endurance of supine, side lying, and prone
posture were significantly improved in the WE and SWE groups.
Conclusions: Lumbar SE and WE can be recommended for patients with chronic LBP because they not only relieve back pain but
also prevent chronic back pain through improving muscle endurance.
Abbreviations: FE = flexibility exercise, IGLSE = individualized graded lumbar stabilization exercise, LBP = low back pain, SE =
stabilization exercise, SWE = stabilization with walking exercise, VAS = visual analog scale, WE = walking exercise.
Keywords: low back pain, lumbar stabilization exercise, walking

Editor: Hyunsik Kang.

This work was supported by Research Resettlement Fund for the new faculty
of SNU. This research was supported by Basic Science Research Program
1. Introduction
through the National Research Foundation of Korea (NRF) funded by the Low back pain (LBP) is one of the most common musculoskeletal
Ministry of Education (NRF-2016R1D1A1B03935130 to Ju Seok Ryu, MD,
PhD (Department of Rehabilitation Medicine, Seoul National University disorders, with a prevalence rate of 80%. [1] In some patients, the
Bundang Hospital, Seoul National University College of Medicine, Seongnam- initial acute pain may continue during a 3-month period and
si, Gyeonggi-do, South Korea). eventually develop into chronic LBP. Chronic LBP is associated
No commercial party having a direct financial interest in the results of the with histomorphologic and structural changes in the paraspinalis
research supporting this article has or will confer a benefit upon the authors muscles. These back muscles are smaller, contain fat, and show a
or upon any organization with which the authors are associated.
degree of atrophic changes in select muscle fibers.[2] Therefore, the
The authors report no conflicts of interest.
lumbar paraspinalis muscles are weak with excessive fatigability.
Suppliers: a. SPSS for Windows version 21.0, SPSS Inc., Chicago, Illinois, USA. [3,4]
Furthermore, poor coordination of the para-spinalis muscles
a Department of Rehabilitation Medicine, Bobath Children’s Clinic,
b has been associated with chronic LBP. [5] These contribute to a
Yongin, Gyeonggi-do, South Korea, Department of Rehabilitation Medicine, Seoul
National University Bundang Hospital, Seoul National University College of vicious cycle of LBP and deconditioning syndrome.
Medicine, Seongnam-si, Gyeonggi-do, South Korea.
∗ Exercise can improve back extension strength, mobility,
Correspondence: Ju Seok Ryu, Department of Rehabilitation Medicine,
Seoul National University Bundang Hospital, Seoul National University endurance, and functional disability. [6,7] Various exercises, such as
College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, lumbar stabilization exercise (SE), motor control exercise, core
Gyeonggi-do, South Korea, 13620 (e-mail: [email protected]). exercise, lumbar flexion exercise, walking exercise (WE), and
Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc. bracing exercise, have been proposed to mitigate chronic LBP.
This is an open access article distributed under the terms of the Creative These exercises focus on lumbar stabilization and core
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY- strengthening.[8] However, to date, no one particular exercise has
NC-ND), where it is permissible to download and share the work provided it
is properly cited. The work cannot be changed in any way or used been shown to be superior.[9–11]
commercially without permission from the journal. Lumbar SE is primarily aimed at improving neuromuscular
Medicine (2019) 98:26(e16173) control, strength, and endurance of the muscles, which are
Received: 24 October 2018 / Received in final form: 8 May 2019 / Accepted: considered to be central to the maintenance of dynamic spinal and
2 June 2019 trunk stability. It is considered as a safe exercise with the
http://dx.doi.org/10.1097/MD.0000000000016173 advantages of having multiple stages, as well as

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Suh et al. Medicine (2019) 98:26 Medicine

cost-effectiveness.[12,13] Each individual has different lumbar random allocation sequences that were prepared by a statistician
muscular strengths, and therefore, lumbar SE programs should be not involved in participant recruitment. The randomization
individualized, comprising of various postures with varying schedule was only accessible by 2 individuals: the statistician and
intensities to maximize therapeutic benefit to a particular the primary investigators.
individual.[13] To improve compliance, the intensity level of each
exercise can be modified according to each patient’s capacity, with 2.4. Blinding
changes in the postures of the upper and lower extremities or neck
It was not possible to blind participants and physiotherapists given
as well as changes in the duration of exercise time. [13] Therefore,
the nature of the exercise therapy and evaluation. One researcher
individualized graded lumbar SE (IGLSE) will allow for a
customized exercise program that caters to the needs of a specific blinded to group allocation measured the outcomes at pre-,
patient. IGLSE is not only safe, as it has the ability to strengthen immediately post-, and 6 weeks post-exercise program. Statisticians
the lumbar musculature without flexion or extension, but it also has and primary investigators were unaware of the group allocation
the potential to offer high compliance owing to the graded protocol until data analyses were complete.
with modifiable intensity.
Moreover, walking is highly recommended to rehabilitate 2.5. Exercise protocol
patients with LBP. It is relatively easy to comply with and is highly
cost-effective.[14] It leads to enhanced isometric endurance by Participants underwent each exercise for 30∼60 minutes, 5 times a
increasing muscular endurance and has the potential to eventually week, for a total duration of 6 weeks. All participants were
educated on the correct posture and abdominal bracing method, and
prevent LBP.[15]
received a pamphlet explaining good postures and abdomi-nal
The aim of this study was to investigate the efficiency of IGLSE
bracing method for preventing LBP. Light abdominal bracing
and WE. We hypothesize that these 2 exercises are highly effective
in alleviating LBP and increasing compliance because of their exercise (10%–20% of maximal bracing) was recommended for all
customizability. times; maximal bracing was recommended for 5 to 7 seconds,
intermittently.
The education session was performed at the clinic by a trained
2. Materials and method physical therapist at the first visit. Moreover, a printed pamphlet
This study was a prospective randomized controlled clinical trial with instructions on how to perform the exercises was given to each
with 4 groups: flexibility exercise (FE) group, WE group, SE group, patient. The exercises were performed at home All participants
and stabilization with WE (SWE) group. Subjects in this study underwent a telephone interview every 2 weeks to confirm the
were part of a clinical trial (NCT02938169). The study and all current pain status, degree of exercise compliance, and to adjust the
procedures were approved by the Institutional Review Board of exercise level. Telephone communication also acted as an
Seoul National University Bundang Hospital (B-1604-344-004). encouragement to exercise, promoting compliance.
The FE group received stretching exercise for the abdominal
muscle, quadriceps, hamstring, tensor fascia lata, piriformis muscle,
2.1. Subjects and quadratus lumborum muscles for 30 minutes (Fig. 1A). The
This study was conducted between May of 2016 and April of 2017. WE group performed fast walking on flat ground with abdominal
Patients complaining of chronic LBP were recruited from the bracing for 30 minutes. The SE group was educated on IGLSE,
rehabilitation outpatient clinic. The inclusion criteria were subjects focusing on the modifiable intensity level based on the exercise
older than 20 years with intermittent chronic LBP of >3 months. capacities of each participant. The IGLSE protocol consisted of 2
The exclusion criteria were as follows: a pain intensity of below parts: stretching exercises and SEs (Fig. 1B). All participants
VAS 40 during physical activity, neurologic motor weakness, performed stretching exercises for 5 minutes as a warm-up before
deformity (scoliosis with cobb’s angle exceeding 10 degrees), beginning the SEs for 25 minutes. This program ranged from easy
history of recent lumbar or abdominal surgery, systemic to difficult, based on participants’ exercise capacity. Each exercise
inflammatory disease or psychiatric disease, severe knee or hip level had 7 basic positions: supine, dead bug, side lying, prone, bird
arthritis that may interfere with WE, pregnancy, and previous dog, bridge, and plank (5 levels, Fig. 1B). We gradually increased
exercise treatment for lumbar paraspinalis muscles within 3 the degree of instability until the most unstable posture was
months. The physical examination was done by a physical medicine achieved. At the beginning, participants were placed into a level
and rehabilitation specialist. with moderate difficulty. To challenge the stabilization of all trunk
muscles (anterior, lateral, and posterior), including the transverse
abdominis, rectus abdominis, erector spinae and multifidus, internal
2.2. Sample Size Calculation
oblique abdominals, and quadrates lumborum, participants were
One way analysis of variance (ANOVA) power analysis was instructed to complete all 5 exercise positions in each session.
performed with the help of a statistical team to compare the average Patients repeated each of the 7 postures 5times for about 30
values of the four groups. As a result, the power of 82% was
obtained when 10 patients were allocated to each group. As a seconds each, to the best of their ability, for a total of 25 minutes.
result, 15 patients were assigned to each group to account for a [12,13]
The SWE group performed IGES for 30 minutes
dropout rate of 30%. and walking for an additional 30 minutes.

2.3. Randomization 2.6. Outcome measurement

Consenting participants were randomly allocated to 1 of 4 study The primary outcome was the changes of VAS of LBP from the
groups, following the predetermined and computer-generated baseline to the follow-up. VAS was measured during rest and

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Figure 1. These figures show the exercise protocol for flexibility and lumbar stabilization exercises. Flexibility exercise consisted of stretching in the abdominal
muscle, quadriceps, hamstring, tensor fascia lata, piriformis, and quadratus lumborum muscles (A). The stabilization exercise group was educated with
individualized graded lumbar stabilization exercise (IGLSE). The IGLSE protocol consisted of 2 parts: the stretching exercises and stabilization exercises (B). After
the stretching exercises of 5 minutes, patients were instructed to complete the stabilization exercises for 25 minutes. Each level had 7 basic positions: supine, dead
bug, side-lying, prone, bird dog, bridge, and plank positions (5 levels). At the beginning, patients were placed into an exercise level with moderate difficulty, with
gradual increase in difficulty with increased patient capacity. Squared figures show a specific posture used to measure the muscular endurance for the secondary
outcome. Endurance was measured on 3 postures (supine, side-lying, and prone), respectively.

physical activity. The secondary outcomes included VAS of 2.7. Statistical Methods
radiating pain measured during rest and physical activity, frequency SPSS 21.0 software (SPSS Inc, Chicago, IL) was used for all
of medication use (number of taking medications / day), endurances statistical analyses. Wilcoxon signed rank test was used to compare
of specific posture (Fig. 2, squared posture), and strength of lumbar
the variables before and after the exercise in each group. Kruskal-
extensor muscles. Endurance was measured in 3 postures (supine,
Wallis test was used to compare the 4 groups. Repeated measures
side-lying, and prone).[12] The strength of lumbar extensor was ANOVA was used to compare the pain scores (VAS) at various
measured with the manual muscle tester (FEI 12-0380 Lafayette time points: 1st week (preexercise program), 6th week
Manual Muscle Tester, Fabrication Enterprises Inc.) in sitting (immediately post-exercise program), and 12th week (6 weeks
position. In addition, Oswestry Disability Index and Beck post-exercise program). The results are presented as the mean ±
depression inventory were measured to identify kinesiophobia, standard deviation. P values of <.05 were considered statistically
psychosocial aspects, and the disability for LBP. significant.

The first follow-up evaluation was done within 2 weeks after the
3. Results
completion of the 6-week exercise program, and all the initial
evaluations were rechecked (immediately post-exercise program). A total of 60 patients were enrolled in the study. They were
The second follow-up evaluation was performed 12 weeks after the randomly assigned to 1 of the 4 groups, based on the type of
start of the program (6 weeks post-exercise program). At this exercise: the FE group (n =15), WE group (n =15), SE group (n =
evaluation, frequency and duration of exercise, as well as VAS of 15), and SWE group (n =15). Two patients in the FE group, 2
back pain and radiating pain during rest and physical activity, were patients in the WE group, 5 patients in the SE group, and 3 patients
rechecked via telephone questionnaire to investigate the long-term in the SWE group dropped out for personal reasons. The remaining
compliance and effectiveness of the exercise treatment. Participants 48 subjects completed the 6-week exercise program without
were advised to continue the exercise routine for the full duration incident. After 12 weeks, the exercise amount, LBP, and radiating
of the program and that the second follow-up evaluation would be pain were examined via a telephone interview. Thirteen patients in
performed at the 12th week. the FE group, 12 in the WE group, 10 in the SE group,

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Figure 1. (Continued).

and 12 in the SWE group were followed up at 6 weeks after the end Table 3 shows the results of core stability. All groups showed a
of the program (Fig. 2). statically significant improvement in the posterior shear test and
The demographic data of this study are shown in Table 1. The prone instability tests (Fisher exact test, P value of posterior shear
mean age of the entire study population was 54.81 years. There was test was .043 and the P value of prone instability test was .002).
no statistically significant difference with respect to age, sex, Additionally, improvement of prone instability test showed the
exercise frequency, exercise amount, and the frequency of largest improvement in the WE group and smallest improvement in
medication use among the groups (Table 2). There was no the FE group (Table 3).
significant difference in VAS of LBP and radiating pain during rest
and physical activity at baseline. LBP during physical activity was
4. Discussion
significantly decreased in all four groups after the 6-week exercise
program; LBP during rest was significantly decreased in the FE LBP is a public health problem worldwide because of its
group and in the SE group (Table 2). Moreover, the frequency of socioeconomic and psychological impacts, as well as the
medication use was decreased significantly in the FE group. limitations of its preventive or curative treatments proposed to date.
[16]
Exercise frequency was significantly increased in the SE and WE The efficiency—in terms of pain relief and functional
groups, and exercise time was significantly increased in the SE restoration—of the therapeutic approaches based on active exercise
group. According to these results, the highest compliance was seen has been demonstrated in several previous studies. [17,18] Based on
in the SE group (Table 2). literature review, physical exercise can help those suffering from
The WE and SWE groups showed a significant increase in the chronic LBP by allowing the resumption of daily activities. [19] In
endurance to maintain prone, supine, and side-lying positions particular, the supervised exercise therapy is
(Table 2). Moreover, the Oswestry disability index and Beck recommended by the European Guidelines for Management of
depression inventory were significantly improved in all 4 groups, Chronic Non-Specific LBP as the first-line treatment.[20] However,
and there was no significant difference between the 4 groups. In these guidelines do not recommend a particular exercise; hence, the
addition, there was no statistically significant difference between choice of exercise for chronic LBP largely depends on the
the 4 groups with respect to LBP and radiating pain at pre-, preferences of patients and/or therapists, as well as cost and safety.
[21–24]
immediately post-, and 6 weeks-post exercise time points using the It is important for an exercise therapy to be simple, cost-
repeated measures ANOVA (Table 2, Fig. 3). Although statistically effective, and easy to perform to maximize compliance.
insignificant, the SE and WE groups showed more continuous Given these considerations, IGLSE and WE appear to be most
improvement in LBP during rest and physical activity than the FE appropriate, and as such, we evaluated the effectiveness and com-
group (Figure 3A, B, D). pliance of these 2 exercises. For ethical reasons, we were unable

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Figure 2. This figure shows the study flow diagram.

to use a placebo group for comparison; therefore, we compared under excessive loading conditions and shown to be a source of
these 2 exercises to a widely popular and highly efficacious FE. LBP.[25] The correct lumbar posture emphasizes the significance of
Although we anticipated higher efficiency of IGLSE and WE lumbar lordosis, which is effective in the prevention of lumbar disc
than FE, LBP during physical activity was improved in all 4 protrusion. Moreover, abdominal bracing exercise is one of the
groups, and there were no significant differences between the most effective ways to induce a higher activation of deep
groups. We believe the reason for this is likely because the abdominal muscles, such as the internal oblique muscle;
participants were correctly educated on lumbar posture and bracing this is so even when compared with dynamic exercises that involve
exercise (Fig. 4A). Correct posture is a simple but very important flexion/extension movements of the trunk.[26,27] We
way to keep many intricate structures of the back and spine healthy. educated the participants on the proper protocol and verified every
The myoelectric silencing of the erector spinae muscles in the trunk 2 weeks whether they were performing the exercises as instructed.
flexion posture suggests increased load sharing on passive We believe that played a major role in all 4 groups showing
structures; tissues have been found to fail significant improvement in pain relief. Moreover,

Table 1
Demographic data.
Variables Flexibility exercise Walking exercise Stabilization exercise Stabilization with walking exercise Total
Age, y 53.54±15.69 54.15±13.89 57.40 ±15.88 54.75 ±14.98 54.81 ±14.66
Sex (M:F) 5:8 2:11 4:6 4:8 15:33
Exercise amount, min/wk 175.29±155.70 181.54±217.32 291.00 ±224.19 213.33 ±173.84 210.60 ±192.09
Medication, per day 0.86±1.25 0.33±0.62 0.40 ±0.70 0.92 ±1.38 0.63 ±1.05
Values are mean ± standard deviation or n.

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Suh et al. Medicine (2019) 98:26 Medicine
 exercise
After 12 wk
—
±783. 2.32
±34.23.2077
±8320.26.44
±39.25.4455
Stabilizationwithwalk ing
after6weeks,and12weeks
able 2 ofexercisein4groups. PreAfter6wk
PreAfter6wk
omparison between preexercise, After6wkAfter12wk
Flexibilityexercise ±160.0.37
Walkingexercise Stabilization wkAfter ±±92330.1.380.0.78
±330.0.62
±±33793.2.714.1.79

±±04554.1.833.2.21
±340.0.65 ±384.1.69 ±542.2.81
PreAfter6 exercise
0.67
±±51.83.1546.22.039292 ±±54.49.58 45.23. 8417 00

edication, Pre
±860. 1.25 ∗ — ∗ ∗ ±0 025. 20.1 0
After 12 wk 400. ∗ ∗∗∗ ±300. ±0.70 ∗ ∗∗∗ 12 wk
0.97
11.07
—±063.2.36 ±0030.30.38
±5830.20.92
±36. 22. 4054
xercise frequency,
per day per ±912. 2.58 ∗∗ — ±352. 1.56±59.11.4561
653. ±505. ±1.81 20.21 ±59.22.6158
xercise time, min ±65. 85.4400 ±35.39 19.73 ∗∗ ±32. 22.2105 ∗ ∗ ±28. 33.3064 69.00 ±36.50 ±35.50 20.82
±31. 19.8111 ∗
ain intensity
Pain
hysical
intensityduring
during ±9241. 23.32
±68. 17.5885 ±8927.
±37.69 18.54
16.28 ±5032. 21.79
±36. 22.4715 ±0020. 17.58
±30. 21.3200 5037.
69.00 ±2524. ±14.49
±35.75±21.76 ±5022. 23.72
±26. 23.0700 ±3318. 20.93 ∗
±33. 23.8733

activity —— —— —— ——
±41. 15.3125 ±50. 16.6506 ±29. 13.5386 ±43. 18.8330 ∗∗ ±51. 12.4045 ±45. 14.0106 ±35. 20.6414 ±43. 17.8179 ∗∗

Supine1, s

±35. 18.7111 ±46. 17.6525 ±25. 12.9939 ±38. 18.9993 ±40. 16.9720 ±47. 14.3219 ±31. 20.7966 ±43. 18.1840

Supine2,
s
 motion.[15] Previous gait analysis showed that chronic LBP patients
although not significant, tend to have a slower walking speed when compared with healthy

±1637.24.33
±31.18.69
it is thought that the

—
——
——

—
control subjects; moreover, it also showed diminishing normal
decrease in velocity-induced transverse count-er-rotation between the thorax

±5842.20.73
±6224.22.34
±5640.22.30
radiating pain, as shown

±24.12.39

±10.9.27

±10.6.78
and pelvis.[30] WE induces
∗

∗
in Figure 3C and D,
may be because of the isometric contractions by increasing muscular activation, which

∗
may eventually lead to the prevention of LBP. [31] In the present
±9648 . 18. 11

±3244 . 15. 94
±0 635. 24.8 2

±2 622. 16.7 0

∗ spontaneous regression

∗
of herniated lumbar study, we recommended fast walking while maintaining proper
∗

disc[28,29] and posture. Previous study showed that fast WE activates lumbar
improvement of multifidus muscles more than slow WE and that increasing walking
stability of the slope activates the mid-lumbar muscles more than lower lumbar

18.860
paraspinalis muscles muscles.[31] Prolonged activation of lumbar paraspinalis muscles
19.24
19.60
±0123. 18.87
±38. 21.10
and lumbar lordosis. have muscular strengthening effects; therefore, the paraspinalis
±6027. 17.89
±9411. 17.32
±9134. 19.86
±3929. 18.87

7.63
±30. 12.94
±13. 11.93

strengthening effect may be greater in WE s than in other exercises.

±2515.
±3229.
±1428.

±12. In a previous study,

the size and quality of
lumbar paraspinalis Motor control exercise intervention focuses on the activation of
muscles were shown to deep trunk muscles and targets the restoration of control and co-
Beckdepressioninventory
Oswestrydisability index

be important factors for ordination of these muscles, progressing to more complex and
preventing relapse of functional tasks that integrate the activation of deep and global
—
—
—

Sidelying1,s
Sidelying2,s
Prone2(sec)

LBP.[4] Patients with trunk muscles.[21,32] Our hypothesis is that delayed activation of
Prone1,s

chronic LBP tend to deep trunk muscles is not the cause of chronic LBP, but a
±5834.15.17
±8750.15.04

±8248.17.37

±25.9.93

∗
±5.6.23

develop reduced lumbar consequence of disc space narrowing or spinal stenosis. For
±8038.21.55

<.05.P
∗∗

muscle strength due to example, when the lumbar erector spinae muscles—which contract
pain-induced movement the long segments of the vertebrae—loosen 10% and when
reduction. Therefore, multifidus muscles—which contract the short segments— loosen
patients with chronic 20%, disc space narrowing tends to develop (Fig. 4B). As a
LBP should pay close consequence, contraction of deep multifidus muscles in these
attention to various
±3538. 18.29
±6920. 13.98
±2140. 17.84
±1634. 18.08

patients develops later than the healthy population owing to

±31. 13.24

exercises that optimize muscular loosening. Therefore, we adapted a lumbar SE that

±7. 4.82

the improvement of activates not only the deep muscles, but also the superficial muscles
spinal muscle simultaneously, and also developed the IGLSE, which can easily be
weakness. To applied to improve compliance. The present study showed that
strengthen lumbar exercise frequency and exercise time, which can be used to measure
paraspinalis muscles,
———

compliance, were significantly increased in the SE group,

we adapted IGLSE and suggesting high compliance (Table 2). In this exercise protocol,
WE. In the present
±22.7.45

patients were initially placed into an adequate, yet somewhat

∗∗∗

study, WE showed a difficult exercise level, with an incremental increase in the degree
±8.7.16
±9935.17.86

±9822.23.27

±2345.18.89

±2033.19.74

significant lumbar
of difficulty within a 30-minute period.[12] Increased muscular
strengthening effect.
∗∗

activations in various postures were proved with previous surface

Walking is widely
accepted as a good electromyography.[13] We found that multiple postural changes may
choice for general back be beneficial to ensure better compliance with exercises, as both
exercise and motivation and positive perception of exercises are necessary for
±2334. 19.74

±0531. 18.10
±8417. 14.91

rehabilitation programs, treatment compliance. The short duration programs and minimal
±506. 4.02

±28. 12.81
±10. 7.35

as it strengthens the postures in the 7 basic positions and hospital-based home exercise
back muscles and programs are thought to be the main factors of high compliance. [12]
reduces rigidity of
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Suh et al. Medicine (2019) 98:26 www.md-journal.com

Figure 3. These figures show the changes of LBP and radiating pain during rest and physical activity, although statistically insignificant, the stabilization exercise
group and walking exercise group showed more continuous improvement of LBP during rest and physical activity than the flexibility exercise group (A, B, D).

At the 6th week, the exercise time of the 4 groups was 35∼46 physical endurance. Considering the efficiency of the WE and the
minutes. According to the study design, the exercise time of the SE on reducing pain and improving the physical endurance, it is
SWE group should be twice as long as that of the other groups. recommended that these interventions should be applied to treat
However, the patients who have chronic LBP usually show atrophic chronic LBP.
changes in lumbar paraspinalis muscles. [2,4] So, it seemed that 60
minutes of exercise was difficult to do in chronic LBP patients. In 4.1. Study limitation
fact, the frequency of exercise was significantly increased in the
WE and SE groups after the study compared with before the study; There are some limitations of this study. First, the causes of LBP
however, this trend was not observed in the SWE group. It is were heterogeneous. Nonetheless, this study is still valuable as the
assumed that compliance may fall with prolonged exercise time purpose of the study was to determine an effective exercise method
that exceeds patient ability. In future studies, it would be important to solve general LBP. Second, the full extent of the effect of SE,
to select an exercise program of around 30 minutes. WE, and FE on LBP may be limited as abdominal bracing exercise
and correct posture training were performed in all 4 groups owing
The present study suggested that the stabilization and WE s to ethical reasons. Third, the short study period may be a limiting
might have some favorable effects on the muscle strength and factor of this study. In the next study, it will be

Table 3
Comparison of tests for examination of LBP.

Flexibility exercise Walking exercise Stabilization exercise Stabilization with walking exercise

Active bilateral SLR test Pre 8 (61.54%) 9 (69.23%) 5 (38.46%) 8 (61.54%)

Post 6 (46.15%) 7 (53.85%) 4 (30.77%) 4 (30.77%)
∗
Posterior shear test Pre 5 (38.46%) 7 (53.85%) 2 (15.38%) 5 (38.46%)
∗ ∗ ∗ ∗
Post 4 (30.77%) 4 (30.77%) 1 (7.69%) 4 (30.77%)
∗
Prone instability test Pre 5 (38.46%) 11 (84.61%) 4 (30.77%) 2 (15.38%)
∗ ∗ ∗ ∗
Post 4 (30.77%) 2 (15.38%) 2 (15.38%) 1 (7.69%)
LBP =low back pain, SLR =straight leg raise. Values are number.
∗

P <.05.

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Figure 4. Figure (A) shows the pamphlet illustrating the correct postures. The correct lumbar posture emphasizes the significance of lumbar lordosis,
which is effective in preventing lumbar disc protrusion (A). Figure (B) shows the rationale of why we adapted lumbar stabilization exercise that activates
not only the deep muscles but also the superficial muscles simultaneously rather than motor control exercise. When lumbar 4-5 disc herniation develop,
more loosening is developed at the multifidus muscle (eg, 20%) than the erector spinae muscle (eg, 10%). As a consequence, contraction of the deep
multifidus muscles in these patients develops later than healthy population because of muscular loosening (B).

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Suh et al. Medicine (2019) 98:26
necessary to examine the effects of lumbar SE in chronic LBP by www.md-journal.com
lengthening the study period. Fourth, the drug type and potency
were not considered in this study. The lack of comparability of drug
radiologic diagnosis of spondylolysis or spondylolisthesis. Spine (Phila Pa
potency may be a limitation. Fifth, the American College of Sports
1976) 1997;22:2959–67.
Medicine minimum exercise guidelines recommend 20 minutes of [9] Geneen LJ, Moore RA, Clarke C, et al. Physical activity and exercise for
aerobic activity, 3 days per week, and 1 set of 8 to 12 resistance chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database
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Author contributions back pain. Eur Spine J 2006;15(suppl 2):S192–300.
[21] Saragiotto BT, Maher CG, Yamato TP, et al. Motor control exercise for
Conceptualization: Ju Seok Ryu. chronic non-specific low-back pain. Cochrane Database Syst Rev 2016;
Formal analysis: Jee Hyun Suh, Gwang Pyo Jung. Cd012004.
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Writing – original draft: Jee Hyun Suh.
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