00022

A COMPARISON OF TWO FORMS OF PERIODIZED
EXERCISE REHABILITATION PROGRAMS IN THE

MANAGEMENT OF CHRONIC NONSPECIFIC
LOW-BACK PAIN
ROBERT T. KELL1
AND
GORDON J.G. ASMUNDSON2
Augustana Faculty, Department of Social Sciences, University of Alberta, Camrose, Canada; and
Faculty of Arts, Department of Psychology, University of Regina, Regina, Canada
ABSTRACT
Kell, RT, and Asmundson, GJG. A comparison of two forms of
periodized exercise rehabilitation programs in the management
of chronic nonspecific low-back pain. J Strength Cond Res
23(2): 513523, 2009The purpose of this study was to
determine the influence of 2 different periodized exercise
rehabilitation programs (resistance training [RT] and aerobic
training [AT]) on musculoskeletal health, body composition,
pain, disability, and quality of life (QOL) in chronic ($3 months;
$3 dwk21) nonspecific low-back pain (CLBP) persons.
Twenty-seven CLBP subjects were randomly assigned to 1
of 3 groups, 1) RT (n = 9), 2) AT (n = 9), or 3) control (C; n = 9).
Subjects were tested at baseline and at weeks 8 and 16 of
training. Intensity and volume were periodized in the training
groups. Significance was set at p # 0.05. No significant
differences were noted among the groups at baseline. The RT
group significantly decreased body fat percent from baseline to
week 8 and from baseline to week 16, whereas the AT group
significantly decreased body fat percent and body mass from
baseline to week 16. The RT group significantly improved most
musculoskeletal fitness, pain, disability, and QOL outcomes
from baseline to week 8, baseline to week 16, and weeks 8 to
16. However, the AT group showed significant improvements in
flexibility from baseline to week 8 and in cardiorespiratory and
peak leg power from baseline to week 8 and baseline to week
16. The AT groups showed no significant improvements in pain,
disability, or QOL. The primary finding was that periodized RT
was successful at improving many fitness, pain, disability, and
QOL outcome measures, whereas AT was not. This study
Address correspondence to Robert Kell, rob.kell@ualberta.ca.

23(2)/513523
Journal of Strength and Conditioning Research
2009 National Strength and Conditioning Association
indicates that whole-body periodized RT can be used by

training and conditioning personnel in the rehabilitation of those
clients suffering with CLBP.
KEY WORDS aerobic training, disability, strength training,

therapy
INTRODUCTION
pproximately 80% of North Americans will suffer

from low-back pain during their lifetimes (8), and
fewer than 15% of the cases will be diagnosable
(e.g., spondylolythesis), making the most common diagnosis chronic nonspecific low-back pain (CLBP)
(34). Chronic nonspecific low-back pain refers to pain associated with the soft tissue (ligaments, tendons, skeletal
muscle) of the low-back area. Recently, deconditioning was
purported to be associated with CLBP (30), which may be
related to lower physical activity levels (deconditioning
reduced muscular strength and aerobic fitness) (32). Moreover, reduced health and fitness was shown to diminish the
quality of life (QOL) of people suffering from chronic disease;
conversely, improved health and fitness was shown to
improve QOL (16).
A potential intervention that may address a broad range of
QOL issues (e.g., physical, functional, emotional, social) in the
CLBP population is physical exercise. Exercise is associated
with numerous physiological and psychological benefits in
nondiseased populations that are characteristically diminished in diseased populations (5). However, to date, CLBP
exercise rehabilitation programs have met with moderate
success in addressing physical function, pain, disability, and
QOL issues. The types of programs that have been implemented range from aerobic exercise (18), back school (9),
stretching (21), core area (i.e., rectus abdominus, internal and
external obliques, and erector spinae) strength development
(9), and whole-body resistance exercise (26,31). Additionally,
these programs have often used a basic progressive overload
approach to rehabilitation, frequently focusing on the core
area and not whole-body musculoskeletal health.
VOLUME 23 | NUMBER 2 | MARCH 2009 |
513
Copyright N ational S trength and Conditioning A ssociation. Unauthorized reproduction of this article is prohibited.
Periodized Exercise Rehabilitation for Chronic Nonspecific Low-Back Pain Management

In contrast to basic progressive overload, when preparing
athletes for the competitive season it is necessary to set
a strong physiological foundation from which to work. This
foundation is set during the preparatory phase to expand the
athletes physical work capacity (3). When an athletes work
capacity is increased, the risk of injury during training and/or
competition is decreased (39). The type of program
frequently used by training and conditioning personnel is
a periodized training model, which is considered more
effective at improving physiological function than nonperiodized models (e.g., basic progressive overload) (23).
Additionally, periodized strength training can lead to
substantial increases in muscular strength and mass even in
older men and women (14). Thus, periodized training is
a safe method of training even for older adults, as well as
those in pain (e.g., fibromyalgia) (12). The reason for the
success of periodization is the progressive adjustment of
volume and intensity (3). It seems reasonable to consider
a periodized training model in the rehabilitation of those with
CLBP.
The present study used 2 modes of periodized exercise
rehabilitation: 1) resistance training (RT) and 2) aerobic
training (AT). A similar RT program had been used previously
in our lab (25,28), whereas the AT program was newly
developed. The purpose was to determine the influence of
these 2 periodized training programs on musculoskeletal
health, body composition, pain, disability, and QOL. The
hypothesis was that both the periodized RT and AT
programs would demonstrate significant improvements in
the outcome measures from baseline to week 16, whereas the
control group would not.
METHODS
Experimental Approach to the Problem
First, a methodological limitation often encountered in CLBP

rehabilitation literature is concurrent treatments (e.g., RT
combined with stretching). If the CLBP sufferers symptoms
decline, it cannot be determined which mode of rehabilitation
was responsiblethe RTor the stretching. Thus, the results are
confounded. The present study sought to eliminate this
problem by isolating 2 forms of exercise rehabilitation, RTand
AT, and stopping all other exercise modes for the period of
the study. Second, because deconditioning is suggested to be
associated with CLBP, this study sought to increase the
fitness levels of CLBP sufferers who had low physical activity
levels and had never engaged in professionally designed
fitness programming. Third, 2 forms of exercise training that
stress the whole body but at the same time are generally
opposite in effect were selected. This allowed the examination
of 2 different modes of whole-body exercise rehabilitation
that would result in improved whole-body fitness. Fourth, and
most important, exercise rehabilitation programs to date have
used basic progressive overload exercise. Although progressive exercise will overload the physiological structures of
the body, research has shown that periodized programming is
514
the
more effective (e.g., athlete training). Thus, both the RT and

AT programs used traditional periodization as the foundation.
The goal of this study was to implement 2 forms of periodized
musculoskeletal rehabilitation training that exercise the
whole body (i.e., RT and AT), with the intent of determining
the influence on musculoskeletal health, pain, disability, and
QOL, because these measures have been shown to be reduced
in those with CLBP.
Subjects
The subjects were recruited via advertisement from the city of

Regina, with the study beginning in midsummer and ending
in late fall. Subjects received an orientation to the study, read
the information letter, were informed of the experimental
risks, and signed an informed consent document before the
investigation. The investigation was approved through the
University of Regina research ethics board for the use of
human subjects. Potential subjects were excluded from
participation if they had received a diagnosis by a physician
with any of the following: pain below the knee, spinal stenosis,
a herniated or ruptured disc, spondylolythesis, infection in the
lumbosacral area, tumors, scoliosis, a rheumatologic disorder,
osteoporosis, or previous back surgery. Also, persons were
excluded if they had a medical history of metabolic,
endocrine, cardiovascular, or neurological disease. All subjects suffered from chronic ($3 months, $3 dwk21)
nonspecific (soft tissue in origin) low-back (lumbar 5 to
lumbar 1) pain. The mean duration of pain was 27.6 months
(range 696 months). The 27 subjects were randomly
assigned to 1 of 3 groups, which included 1) RT (men
n = 6, women n = 3), 2) AT (men n = 5, women n = 4), and
3) control (C; men n = 5, women n = 4). The subjects physical characteristics were as follows: RT: age 40.1 6 8.7 years,
height 1.74 6 0.08 m; AT: age 36.7 6 8.9 years, height 1.73 6
0.10 m; and C: age 35.3 6 7.3 years, height 1.70 6 0.11 m. At
baseline, there were no significant differences (p # 0.05) in
age, height, body mass, or body fat percentage among the 3
groups (Table 1). Before the study, the subjects physical
activity levels were low (Godin Leisure-Time Exercise
Survey, mean = 9.5, range 622) (11), with no history of
formal exercise training (e.g., RT or AT). Thus, as
demonstrated by the Godin Leisure-Time Exercise Survey,
the subjects were untrained. Initially, there were 33 subjects
in the study, but 6 subjects dropped out, leaving 27 who
completed the 16-week study.
Procedures
The duration of the study was 18 weeks, with 16 weeks of

exercise training and testing (Figure 1). All testing sessions
were conducted by the same 2 researchers. The subjects were
tested at baseline (pretraining) and then randomly assigned
to 1 of 3 groups (RT, AT, or C). The C group was tested on
2 occasions (baseline and week 16), whereas the RT and AT
groups were tested on 3 occasions (baseline and weeks 8 and
16). After baseline laboratory testing, those subjects assigned
to the RT group completed 10-repetition maximum (RM)
TM
the
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rehabilitation began. The baseline laboratory testing supported the Godin Leisure-Time Survey results, indicating
TABLE 1. Body composition.
that the subjects were untrained and deconditioned. Subjects
assigned to the C group were required to maintain their
Baseline
Week 8
Week 16
previous levels of physical activity. Once the study was
complete, the C group subjects were provided either a 16Mean
SD Mean SD Mean SD
week RT or AT program on request, with the intent of
Body mass (kg)
providing the same benefits to the C subjects as the others.
RT 88.4
22.4 89.5 21.5 89.5 21.0
The RT group performed upper- and lower-body RT
AT 81.7 11.5 79.6 11.2 79.2 10.8
exercises that consisted of free weights (i.e., barbell and
C 87.4
28.0
nt
nt
87.7 28.6
Body fat (%)
dumbbell), machines, and body weight (Table 2). The
RT 27.9*
7.4 25.5
6.8 24.2
6.4
resistance machines used were Atlantis Strength Equipment
AT 30.1
9.2 29.2
9.3 28.1
9.0
products (Laval, QC, Canada), which allowed for full range
C 31.6
13.7
nt
nt
31.4 13.7
of motion, smooth action, and easy pin adjustment of the
RT = resistance training; AT = aerobic training; C =
load. The load (resistance) for each exercise was determined
control; nt = no test completed at that time point.
at baseline and week 8 according to the 10RM method. This
*Significant difference (p # 0.05) within group
enabled the establishment of new loads for each exercise to
between baseline and week 8.
Significant difference (p # 0.05) within group
continually stress the bodies of the RT group throughout the
study. The baseline 10RM testing session was supervised to
teach the subjects proper exercise technique, and how to
correctly determine and record their 10RMs for each
exercise. The RT sessions were carried out at the University
testing on 11 resistance exercises (Table 2). Of note, during
of Regina fitness and lifestyle center. The fitness and lifestyle
both the abdominal and Swiss ball crunch, the subjects tested
center had 2 staff members on the workout floor at all times,
first with body weight, and, if necessary, additional free
and the staff were familiarized with the research study and
weight was added, with the subject holding the free weight
the RT exercises used in the study. A traditional periodized
on his or her chest. The prone superman was not used during
training program was used, consisting of 3 sessions per week,
10RM testing. After the baseline laboratory and 10RM tests
intensity range 5372% 1RM, with 13 minutes of rest
were complete, the RT and AT program data were entered,
between sets and exercises (3). The rest time was dependent
subjects were then given programs, and exercise
on the load (1215RM = 1 minute of rest on all exercises;
#10RM = 3 minutes of rest
on primary exercises). Primary
exercises were leg press, bench
press, and incline bench press.
In contrast to the other exercises, the prone superman was
body weight resistance only.
The subjects completed 10
repetitions each set, with
pauses ranging from 5 to 30
seconds per repetition. The
progressive overload was administered by increasing the
duration of the pause (isometric
contraction of the erector spinae), which was governed at
the discretion of the subject.
The RT group subjects were
asked to follow the exercise
Figure 1. The study began with an orientation and completion of necessary paperwork (e.g., informed consent) for
order as defined within the
interested subjects, followed by baseline laboratory testing (randomization into groups: resistance training [RT], n = 9;
program. All the RT exercises
aerobic training [AT], n = 9; and control [C], n = 9) and for the RT groups individual 10-repetition maximum (RM)
testing. The test data were entered, and both RT and AT programs were formatted and provided to the respective
were performed using concensubjects. The subjects trained for 7 weeks, followed by laboratory testing (week 8), and the RT group completed
tric and eccentric muscle ac10RM testing (week 8) on the resistance exercises. Subjects trained another 7 weeks, followed by laboratory
tions in smooth, controlled
testing (week 16). Significance was set at an alpha of 0.05 (p # 0.05).
motions. As previously stated,
515
TABLE 2. Exercises, primary agonist muscles, and equipment.

Resistance exercises
Primary agonist muscles
Equipment type
Leg press
Leg extension
Leg curl
Bench press
Incline bench press
Lat pull-down
Db shoulder press
Straight bar arm curl
Triceps pushdown
Abdominal crunch
Swiss ball crunch
Prone superman
Gluteus maximus
Quadriceps femoris
Hamstring, gracilis, sartorius
Pectoralis major
Pectoralis major
Latissimus dorsi
Deltoid
Biceps brachii
Triceps brachii
Rectus abdominus, internal and external obliques
Rectus abdominus, internal and external obliques
Erector spinae
Machine
Machine
Machine
Free weight
Free weight
Machine
Free weight
Free weight
Machine
Body weight/free weight
Body weight/free weight
Body weight
the prone superman also contained an isometric contraction.

This type of periodized RT program has been used in our
previous training studies (25,28).
The periodized progressive overload AT program consisted
of 3 sessions per week, a Borg scale range of 812, session
duration of 2035 minutes, and a total weekly duration of 55
155 minutes (Table 3). The mode of AT exercise consisted of
any form of aerobic exercise in which the subject was
interested, with the most commonly selected modes being
the elliptical trainer and treadmill walking or jogging. The
only mode of exercise excluded was swimming, because of
the body positions effect on heart rate and the potential
influence on the exercisers rating of perceived exertion
(RPE). The option to self-select the mode of AT was
provided to increase retention and improve generalizability
to the real-world setting. During the laboratory testing
session, the subjects were familiarized with the use of the
Borg scale for rating perceived exertion. The intent was to
use the Borg scale to set the intensity of the AT sessions,
negating the need for a heart rate monitor.
Body composition and anthropometric measures were
standing height, body mass, and body fat percentage, measured in the exercise physiology lab. Standing height was measured with a metric wall tape, set square, and wooden board
(nearest 0.5 cm). Body mass and composition were measured
on a Tanita BF 681W (bioelectrical impedance) body composition scale to the nearest 0.1 kg and 1% body fat. Body
composition measurements were performed with the subject
having clean bare feet, at the same time of day and with the
same hydration level to ensure validity and reproducibility.
Body composition was monitored to provide an indicator of
training program effectiveness and because some research has
suggested a relationship between CLBP and obesity (36).
The subjects were instructed concerning the exact
performance of all laboratory tests before testing to ensure
a safe technique and maximal effort. The researcher provided
516
the
encouragement to all subjects in an attempt to elicit a maximal

effort. The free-weight bench press was conducted on a flat
bench with an Olympic-style bar and weights. The bench
press test was a 10RM effort determined within 4 setsthat is,
1 warm-up set followed by 3 challenging sets of increasing
load (kg). Its purpose was to determine upper-body strength.
The rest time between each set was 3 minutes. The subject
was positioned supine on the bench press. The subject
grasped the bar with his or her hands approximately shoulder
width apart, and then the subject extended his or her arms at
the elbow, removing the bar up off the supports. The bar was
then lowered (under control) to the chest, and then, in
a smooth motion, it was pushed back up, extending the
elbows and returning to the starting position. Lowering the
bar to the chest and then pushing the bar back up to the start
position was considered 1 repetition of that exercise; this was
repeated 10 times (repetitions).
The Biering-Sorensen Back Endurance (BSBE) test was
used to assess low-back isometric muscular endurance, which
tends to be reduced in those with CLBP (29). The procedure
for the BSBE test has been described previously (20). The
subject was placed in a prone position on the horizontal plinth
so that the iliac crest was at the breakpoint in the plinth. Two
straps were fastened at the subjects gluteal and ankle regions.
Once the subject was ready, the upper-body support was
removed to initiate the BSBE. The subjects arms were folded
across his or her chest for the duration of the test. A
horizontally neutral position was maintained via contraction
of the erector spinae, gluteal, and hamstring regions. The
subjects position was monitored by the researcher. Once the
subject was unable to maintain the necessary horizontal
position for 2 seconds, the test was terminated. Each subjects
RPE was assessed with the Borg scale (15-grade scale, anchors
6 and 20) at the completion of the BSBE.
The abdominal curl-up tests measured the muscular endurance of the abdominal muscles, which, as with low-back
TM
the
TM
3
13
155
3
12.7
140
3
11.9
135
3
10.5
100
3
12.2
115
3
11.8
110
3
10.4
90
3
12.5
105
3
11.8
100
3
10.9
95
3
10.0
60
3
10.8
90
3
10.5
85
3
11.4
95
812
3
812
3
1215
3
12
3
812
3
812
3
12
3
815
3
815
3
1015
3
15
2
15
2
15
2
12
2
3
72
3
70
3
65
3
60
3
69
3
68
3
60
3
67
3
67
3
55
3
55
3
65
3
60
3
53
Resistance training
Days per week
Intensity (% 1-repetition
maximum)
Repetitions per set
Sets of each exercise
Aerobic training
Days per week
Intensity (Borg scale)
Duration (min)
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 9 Week 10 Week 11 Week 12 Week 13 Week 14 Week 15
Training groups
TABLE 3. Average values for the resistance and aerobic training programs.
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endurance, is suggested to be reduced in those with CLBP

(29). The test was terminated when the subject was unable to
maintain the required cadence or unable to maintain the
proper curl-up technique for 2 consecutive repetitions
despite feedback from the researcher. A maximum of 3
corrections were allowed by the appraiser before termination
of the test. The subject was positioned supine with the head
resting on the mat, arms straight at sides and parallel to the
trunk, palms of hands in contact with the mat, and the middle
finger tip of both hands at the 0 mark (identified by a piece of
tape). Knees are bent at 90, and the heels are kept in contact
with the mat. The test is performed with shoes on. Cadence
was set by a metronome (50 bpm). The test started with
a slow curling up of the upper spine far enough so that the
middle finger tips of both hands reached the 8-cm mark
identified by tape. During the curl-up, the palms and heels
remained in contact with the mat. On return, the shoulder
blades and head had to contact the mat, and the finger tips of
both hands had to touch the 0 mark. Each subject completed
as many repetitions as possible.
Flexibility of the low back and hamstrings was assessed
using the flexometer during a sit-and-reach test. The subjects
warmed up for this test as it followed the V_ O2max test. The
subjects, without shoes, sat with their legs fully extended and
the soles of their feet placed flat against the flexometer.
Keeping their knees fully extended, arms evenly stretched,
and palms down, the subjects bent and reached forward in a
smooth, controlled effort and held for 2 seconds. The procedure was repeated twice, with the highest result recorded
(nearest 0.5 cm).
Leg extension and flexion power were measured using the
Cybex II isokinetic dynamometer (Cybex International,
Medway, Mass). The Cybex was set for testing with the
lever arm attached to the midline and the axis of rotation
aligned with the anatomic axis of the knees rotation. To
stabilize the knee and hips, the subjects were seated in the
Cybex chair with a back support and were strapped just
superiorly to the knee and at the level of the pelvis. The angle
of flexion at the hip joint was approximately 100, with the
starting position of the knee joint at 45 of flexion. Each
subject crossed his or her chest with his or her arms and was
asked to keep his or her upper body as still as possible while
completing the repetitions. Knee extension and flexion power
were measured unilaterally on the right leg. Once the equipment was calibrated for range of motion and weight of limb
(i.e., lower leg), the subjects performed 3 warm-up repetitions.
After the warm-up, the subjects performed 5 maximal voluntary contraction (extension-flexion) at 180s21. The highest
peak torque value was recorded in newton-meters (1).
The V_ O2max test was conducted using an upright
stationary Monarch cycle ergometer, with the purpose of
monitoring the effectiveness and setting the intensity of the
AT program. The protocol was incremental in nature, with
1-minute stages to V_ O2max or volitional fatigue. Men started
at a resistance of 1 kp, and women started at 0.5 kp, with
517

increases of 0.5 kp per minute for both men and women. The
subjects maintained pedal cadences between 60 and 65 rpm,
with the exception of a sprint near the end of the test to elicit
V_ O2max. Each subjects RPE was recorded at the end of each
1-minute work stage (4). A ParvoMedics (Sandy, Utah)
metabolic analyzer was used to measure breath-by-breath
cardiorespiratory responses. The flowmeter was calibrated
using a 3-L syringe of air. Heart rate (bpm) was recorded via
a wireless Polar Heart Rate (Polar Electro Canada Inc,
Lachine, Canada) chest monitor. The oxygen and carbon
dioxide analyzers were calibrated pre- and posttest with
commercial gases (16% oxygen, 4% carbon dioxide, balanced
nitrogen). Criteria for V_ O2max (2) were 1) an increase of , 100
mlmin21 or decrease in V_ O2 with increasing workload, 2)
age-predicted (220 2 age) maximal heart rate (HRmax), and
3) a respiratory exchange ratio $ 1.10. At termination of the
V_ O2max test, each subject cycled against minimal resistance
for 5 minutes to assist with recovery.
Subjects completed health surveys at baseline, week 8, and
week 16. These included the visual analog scale (VAS) for the
degree of back pain felt by the subject during a typical week,
the Oswestry Disability Index (ODI), and the Short-Form 36
Health Survey (SF-36). The VAS is a simple visual scale used
to measure how much back pain each person felt (0 = no pain;
10 = maximal pain) (19). The ODI is a disease-specific
outcome measure used in the management of spinal
disorders (0 = no disability; 100 = maximum disability)
(10). The SF-36 is a comprehensive measure of health status
(QOL) that contains 36 items and that, when scored, yields
8 domains (parameters): physical functioning, physical role,
bodily pain, general health, vitality, social functioning,
emotional role, and mental health (6). The domains are
scored on a scale from 0 (worst possible health) to 100 (best
possible health). Physical functioning contains 10 items that
assess physical activity limitations (e.g., climbing stairs). The
role physical and role emotional domains measure work or
daily activity problems that result from physical or emotional
health problems. Bodily pain assesses limitations attributable
to pain, whereas vitality measures energy and tiredness. The
social functioning domain checks the effect of physical and
emotional health on normal social activities. Mental health
evaluates happiness, nervousness, and depression. The
general health perceptions domain appraises personal health
and the expectation of changes in health. These 8 parameters
can be used to derive 2 composite scoring summaries:
1) physical composite summary (PCS: physical functioning,
role physical, bodily pain, and general health perceptions)
and 2) mental composite summary (MCS: vitality, social
functioning, mental health, and role emotional) (37).
To assess test-retest reliability, intraclass correlations
(ICCs) comparing baseline with week 16 were completed
using the C group data. The following dependent variables
were tested: sit-and-reach, bench press, BSBE, abdominal
curl-up, leg extension, leg flexion, V_ O2max, HRmax, ventilation max, PCS, and MCS (38). The results demonstrated
518
the
a mean ICC of 0.87 and a range of 0.500.98. The control

group data were used as opposed to the treatment groups
(RT and AT) data because variation was expected within all
groups but particularly within the treatment groups. Thus,
analyses of the C group data were appropriate, but analyses
of the treatment groups data would compromise the validity
of the ICC (Dr. Donald Sharpe, personal communication,
2008).
Statistical Analyses
All values were reported as mean 6 SD or percent change

(%D). Age, height, body mass, body fat, bench press, sit-andreach, BSBE, abdominal curl-up, RPE, peak leg extension
TABLE 4. Muscular strength, endurance, flexibility,

and power.
Baseline
Mean
SD
Week 8
Mean
Bench press (kg)

RT 44.4 23.5 54.3
AT 35.5
10.5 36.6
C 32.3
13.4
nt
Sit-and-reach flexibility (cm)
RT 31.7
7.2 35.4
AT 24.9
7.9 27.6
C 27.6
8.3
nt
BSBE (s)
RT 74.9 36.7 87.2
AT 70.2
17.0 73.3
C 72.9
22.0
nt
RPE (on the BSBE)
RT 15.9
1.2 17.2
AT 16.3
1.9 15.9
C 15.6
1.7
nt
Abdominal curl-ups
RT 18.6 10.7 25.8
AT 18.7
10.7 20.8
C 17.4
9.3
nt
Peak power extension (Nm)
RT 85.7 20.9 93.9
AT 86.0 18.2 86.9
C 81.9
41.0
nt
Peak power flexion (Nm)
RT 50.0 13.0 55.7
AT 47.8
27.6 50.1
C 43.9
16.8
nt
SD
Week 16
Mean
SD
23.9 56.9* 24.2

10.6 37.0 10.4
nt
33.3 13.4
7.6 35.3
6.4 27.9
nt
26.5
7.7
6.0
8.2
37.9 95.0* 38.5

15.5 75.7 14.8
nt
70.9 18.8
1.2 18.1*
1.6 16.7
nt
16.0
0.9
1.8
2.1
8.4 29.6
10.2 22.4
nt
17.9
8.2
9.2
7.0
21.7 97.1
17.4 89.4
nt
83.2
21.4
17.6
37.6
13.0 59.2
25.0 52.3
nt
42.0
12.8
24.6
13.9

control; RPE = rating of perceived exertion; nt = no test
completed at that time point.
*Significant difference (p # 0.05) between RT and C
at week 16.
between week 8 and week 16.
TM
the
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and flexion power, V_ O2max, HRmax, ventilation, respiratory
exchange ratio, VAS, ODI, and SF-36 PCS and MCS were
assessed via a general linear model with repeated-measures
analysis of variance (ANOVA) to compare the RT and AT
groups from baseline to week 8 and week 16. Similarly,
a repeated-measures ANOVA was used to compare the RT,
AT, and C groups from baseline to week 16 (the C group was
not tested at week 8). Additionally, a Levene test for
homogeneity of variances was completed on each dependent
variable during the ANOVA, and, in each case, homogeneity
of variance was found. Intraclass correlations between
baseline and week 16 on the control group data were used
as a measure of test-retest reliability. When a significant F
ratio was achieved, post hoc comparisons were completed
using a Fisher least significant difference. All differences were
considered significant at an alpha of 0.05 (p # 0.05).
RESULTS
Body Composition
No significant differences were apparent among the groups at

baseline, week 8, or week 16 for body composition (i.e., body
mass and body fat) (Table 1). Although there was no
significant difference among the groups at any of the studys
test points, there was a trend for the RT group to increase
body mass while significantly decreasing body fat percentage
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from baseline to week 8 and from baseline to week 16 (Table

1). In contrast, the AT group significantly decreased both
body fat percentage and body mass from baseline to week 16
(Table 1).
Muscular Strength, Endurance, Flexibility, and Power
At baseline, no significant differences were present among the

3 groups in strength, endurance, flexibility, or power.
Similarly, no significant differences were noted between the
RT and AT groups at week 8. However, by week 16, the RT
group had significantly greater bench press strength and RPE
score (on the BSBE) as compared with the C group (Table 4).
When within-group comparisons (overtime) were conducted, it became evident that the RT group made many
significant improvements, whereas the AT groups improvements were marginal. The RT group significantly increased
bench press strength, BSBE time, and peak power on leg
extension from baseline to week 8, from baseline to week 16,
and from week 8 to week 16 (Table 4 and Figure 2).
Additionally, sit-and-reach flexibility, RPE during the BSBE,
abdominal curl-up endurance, and peak power on leg flexion
were all significantly improved in the RT group from baseline
to week 8 and from baseline and week 16. In contrast, the AT
group showed significant improvements in sit-and-reach
flexibility from baseline to week 8 and significant increases
in peak leg extension and flexion power from baseline to
Figure 2. A comparison of resistance training (RT; n = 9; ) and aerobic training (AT; n = 9; n) groups at baseline, week 8, and week 16 on: A) bench press,
B) Biering-Sorensen back endurance test, C) abdominal curl-up, and D) leg extension peak power. Significant difference within group between baseline and
week 8; significant difference within group between baseline and week 16; C significant difference within group between weeks 8 and 16. Significance was set
at an alpha of 0.05 (p # 0.05).
519

week 8 and from baseline to week 16 (Table 4). The tendency
throughout the course of the 16-week study was for the RT
group to improve most muscular parameters from baseline to
week 8, week 8 to week 16, and baseline to week 16, whereas
this was not the case with the AT group.
Cardiorespiratory
At baseline, week 8, and week 16, no significant differences

were found among the 3 groups on any of the cardiorespiratory variables (Table 5). The RT group did not make many
significant improvements in the cardiorespiratory variables,
_
demonstrating a singular but significant improvement in Ve
21
(Lmin ) from baseline to week 8 and from baseline to week
16 (Table 5). However, as expected, the AT group showed
_
significant increases in V_ O2max (mlkg21min21) and Ve
21
(Lmin ) from baseline to week 8 and from baseline to week
_ (Lmin21) from week
16, as well as a significant increase in Ve
8 to week 16 (Table 5). Thus, the AT program improved the
cardiorespiratory performance of the corresponding group,
whereas the RT program did not.
Pain, Disability, and Quality of Life
By the studys conclusion (week 16), the RT groups showed

significant improvements in the VAS, ODI, and SF-36 PCS
and MCS scores compared with both the AT (Figure 3) and C
TABLE 5. Cardiorespiratory.
Baseline
Mean
SD
Week 8
Mean
V_ O2max (mlkg min )

RT 32.2
9.4 34.3
AT 34.5* 7.7 39.3
C 34.8 11.0
nt
V_ E (Lmin21)
RT 72.9* 18.0 76.2
AT 76.5* 18.5 82.1
C 76.8 15.8
nt
Heart rate (bpm)
RT 176.2
7.3 175.8
AT 180.3
7.1 175.8
C 172.6 12.4
nt
Respiratory exchange ratio
RT 1.18 0.08 1.16
AT
1.19 0.08 1.18
C
1.13 0.07 nt
21
Week 16
SD
Mean
SD
8.4
6.2
nt
34.9
41.2
33.1
8.3
5.7
9.3
21
18.3
19.4
nt
77.0 18.1
85.4 18.7
78.6 15.8
6.8 175.8
6.2 175.8
nt 171.3
0.05
0.07
nt
6.8
6.2
9.8
1.13 0.05
1.17 0.04
1.13 0.07

*Significant difference (p # 0.05) within group
520
the
groups, whereas the AT group displayed significant improvements in the ODI and SF-36 MPS compared with the C
group (Table 6). Similarly, as the RT program significantly
increased the muscular outcomes, it also benefited the levels
of pain, disability, and overall QOL across time (within
group). The RT group illustrated significant decrements in
disability (i.e., ODI score) from baseline to week 8, from
baseline to week 16, and from weeks 8 to 16 (Figure 3). Also,
the RT group demonstrated significant reductions in pain
(i.e., VAS score), and improved QOL (i.e., SF-36 PCS and
MCS) from baseline to week 8 and from baseline to week 16
(Figure 3). In contrast, the AT group did not demonstrate any
significant improvements in pain, disability, or QOL. It seems
that improvements in pain, disability, and QOL may be
associated with improvements in musculoskeletal fitness.
However, because of subject numbers (n = 27), we were
unable to perform a multiple regression analysis to directly
address the potential relation between musculoskeletal
variables and pain, disability, and QOL. Thus, we can only
speculate that a temporal relationship exists.
DISCUSSION
This study sought to determine the effectiveness of 2 forms of
periodized trainingRT or ATas rehabilitation strategies for
those with CLBP. In general, the present data provided
further support that periodized exercise training is effective at
inducing meaningful changes in musculoskeletal strength,
endurance, flexibility, and power, as well as aerobic fitness.
However, the findings strongly signify that RT is a more
efficacious mode of rehabilitation for CLBP, and thus the
discussion will focus on the RT group. The development of
musculoskeletal health via periodized RT improved body
composition and reduced pain and disability, recovering
QOL at the same time; this was not the case with the AT
program.
Changes in body composition were marked by a 1.2%
increase in body mass, with a 15% reduction in body fat
percentage. Large improvements in muscular strength and
endurance (27%), power (14%), and flexibility (10%) were
noted with the RT group. Even more important were the
reductions in pain (263%) and disability (267%) and
improved QOL (12%) that were associated with RT. The
findings suggest that traditional periodized RT typically used
by athletes to reduce the risk of injury and improve athletic
performance can also be applied broadly as a musculoskeletal
rehabilitation tool for CLBP. It is likely that the early changes
(~8 weeks) in these musculoskeletal performance outcomes
(i.e., strength, endurance, flexibility, and power) associated
with the RT program were attributable largely to neural adaptations (12). After week 8, muscular hypertrophy became
increasingly important, contributing to musculoskeletal performance in these middle-aged men and women subjects (13).
The influences of the periodized RT program on body
composition and musculoskeletal outcomes have been
demonstrated previously in a range of populations (22,23),
TM
the
TM
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Figure 3. An assessment of the resistance training (RT; n = 9; ) and aerobic training (AT; n = 9; n) groups at baseline, week 8, and week 16 on: A) visual analog
scale for pain intensity, B) Oswestry Disability Index, C) Short Form-36 physical component summary, and D) Short Form-36 mental component summary.
FSignificant difference between the RT and AT groups at week 16; significant difference within group between baseline and week 8; significant difference
within group between baseline and week 16; Csignificant difference within group between weeks 8 and 16. Significance was set at an alpha of 0.05 (p # 0.05).
but this may be the first study to demonstrate these improvements in a CLBP population. Similarly, the improved pain,
disability, and QOL outcomes found in the RT group may be
the first to be documented in the literature. Improvements
in pain, disability, and QOL outcome measures have been
found with other exercise rehabilitation programs (15,18,24)
but not with periodized RT rehabilitation. Of note, these
other exercise rehabilitation programs did not achieve the
same amplitude of increase in muscular strength, endurance,
flexibility, and power as did the present study.
Thus, the present findings are somewhat in contrast to
those from previous CLBP exercise rehabilitation programs
that used resistance, aerobic, flexibility training, and/or
a combination of all and that had moderate success
(18,24,27,31,35). So, why was this periodized RT rehabilitation program more effective than other programs to date?
The basis for the mixed results in previous exercise rehabilitation studies and the results from the present study may reside
in the 1) muscle groups exercised, 2) type of program, and
3) exercise selection.
First, this study did not focus on the core area; instead, it
exercised the majority of the musculoskeletal system (Table
2). Focusing on the core area (i.e., rectus abdominus, internal
and external obliques, and erector spinae muscles) is a common practice with many CLBP exercise rehabilitation
programs (16,27). This may be a potential error in the

rehabilitation of CLBP. It was an objective of this study to
provide a whole-body workout that would sufficiently stress
all large muscle groups to enhance the overall health of the
musculoskeletal system and, consequently, improve physical
function. The rationale for a whole-body exercise regime was
to mimic programs used by athletes that train the entire
body, such as during a preparatory phase of training. One of
the goals of the preparatory phase is to develop work
capacity and general physical preparation, with the development of general fitness being key (3). In the current
study, the approach that was taken in the development of the
RT program was to increase the overall strength and work
capacity of the CLBP subjects but at a more gradual rate than
those used among healthy athletes of the same age. The
schema was to train the CLBP subjects as if they were
chronologically and biologically middle aged, and experientially beginners, with the intent of developing a solid
anatomic and physiological foundation.
Second, most previous CLBP exercise rehabilitation
programs have used progressive overloads in which the
resistance was gradually increased according to each subjects
ability to complete more repetitions at given load than he or
she could previously (17). On reaching the point at which
more repetitions could be completed, the external load
521
TABLE 6. Pain, disability, and quality of life.

Baseline
Week 8
Week 16
Mean SD Mean SD
Mean
SD
Visual analog scale of pain
RT
5.4k 0.9 3.9
AT
5.1
0.8 4.8
C
4.9
0.6
nt
Oswestry disability index
RT 40.4k 2.4 28.2*
AT 39.8
2.3 38.1
C
39.2
3.4
nt
Physical component summary
RT 41.1k 3.2 46.3
AT 42.1
2.5 42.3
C
39.3
3.3
nt
Mental component summary
RT 43.0k 4.1 49.8
AT 44.3
2.3 45.6
C
42.0
3.0
nt
0.8
0.7
nt
3.3
4.8
4.8
0.5
0.8
0.7
2.0
2.2
nt
24.2
35.9*
39.1
2.0
2.5
3.3
3.0
3.2
nt
47.4
41.8
39.1
3.2
2.5
3.3
2.0
2.7
nt
50.6
45.8*
41.56
3.0
1.4
2.3

*Significant difference (p # 0.05) between AT and C
at week 16.
Significant difference (p # 0.05) between RT vs. AT
and C at week 16.
k
(resistance) was increased. This is a relatively typical practice

in exercise rehabilitation. However, the present study used
traditional periodization RT, which is a specific form of progressive overload training. The primary differences between
periodized and nonperiodized progressive overload programs
are the alternating loading schemes (810 and 1215RM)
over successive workouts, whereas a simple progressive overload program uses a traditional moderate-intensity loading
scheme (10RM) with a constant relative intensity (23).
Periodization is considered more effective at improving many
attributes of athletic performance, such as muscular strength,
endurance, and power as compared with nonperiodized
training (23). Of note, in the current study, the RM was
reduced compared with what would typically be implemented in a healthy young athlete, thus safeguarding
against further injury or aggravation of the CLBP subjects
musculoskeletal system, as most were deconditioned before
participating in the study.
Third, the present study employed a mixture of free-weight
(dumbbells, barbells), machine, and body-weight exercises
(Table 2). It is known that free-weight exercises are
associated with greater fatigue in both the synergists and
522
the
stabilizers because free-weight exercises are generally

considered more neurally complex and taxing than machine-based exercises (7). The increased neural complexity
associated with the free-weight component of the RT
program likely resulted in the augmented muscular strength
development (33).
In conclusion, many studies have examined the use of
progressive overload exercise as a rehabilitative tool and have
met with mixed results. To date, many of the training
programs have focused on the core area and used body
weight and/or machine devices to add the external resistance.
However, the periodized RT program in the present study
demonstrated substantial increases in muscular strength,
endurance, flexibility, and power. The increases in most
outcome measures were greater in the RT group than in the
AT group. The improvements in musculoskeletal health
translated into reduced pain, disability, and improved QOL.
The data suggest 3 important points for rehabilitating CLBP:
1) use a periodized training program, 2) exercise a large proportion of the musculoskeletal system, and 3) use a combination of resistance methods (e.g., free weights). Future
research should focus on periodized RT as a form of CLBP
rehabilitation and should determine the upper and lower
ranges of intensity and volume that facilitate improvements
and maintenance of musculoskeletal health and the associated enhancements in pain, disability, and QOL in CLBP
persons.
PRACTICAL APPLICATIONS
This study demonstrates that periodized RTcan be applied to
those with CLBP as a safe and effective form of rehabilitation.
It is the same periodized training framework that is applied to
a healthy or athletic population, with one exception: the
program is more gradual in nature because of the disease state
of the subjects. Consider a basic preparatory phase program
that facilitates the anatomic and physiological readiness of the
client and that progresses from this point according to regular
musculoskeletal reassessments.
ACKNOWLEDGMENTS
Support was provided by the Saskatchewan Health Research
Foundation (New Investigator Grant) and the University of
Alberta, Augustana Campus (travel grant). I am also indebted
to Dr. Donald Sharpe for his assistance with the statistical
analyses.
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A COMPARISON OF TWO FORMS OF PERIODIZED

EXERCISE REHABILITATION PROGRAMS IN THE

GORDON J.G. ASMUNDSON2

Address correspondence to Robert Kell, rob.kell@ualberta.ca.

indicates that whole-body periodized RT can be used by

KEY WORDS aerobic training, disability, strength training,

pproximately 80% of North Americans will suffer

Periodized Exercise Rehabilitation for Chronic Nonspecific Low-Back Pain Management

First, a methodological limitation often encountered in CLBP

more effective (e.g., athlete training). Thus, both the RT and

The subjects were recruited via advertisement from the city of

The duration of the study was 18 weeks, with 16 weeks of

Journal of Strength and Conditioning Research

Journal of Strength and Conditioning Research

Periodized Exercise Rehabilitation for Chronic Nonspecific Low-Back Pain Management

TABLE 2. Exercises, primary agonist muscles, and equipment.

Primary agonist muscles

the prone superman also contained an isometric contraction.

encouragement to all subjects in an attempt to elicit a maximal

Journal of Strength and Conditioning Research

Journal of Strength and Conditioning Research

endurance, is suggested to be reduced in those with CLBP

Periodized Exercise Rehabilitation for Chronic Nonspecific Low-Back Pain Management

a mean ICC of 0.87 and a range of 0.500.98. The control

All values were reported as mean 6 SD or percent change

TABLE 4. Muscular strength, endurance, flexibility,

Bench press (kg)

23.9 56.9* 24.2

37.9 95.0* 38.5

RT = resistance training; AT = aerobic training; C =

Journal of Strength and Conditioning Research

Journal of Strength and Conditioning Research

No significant differences were apparent among the groups at

from baseline to week 8 and from baseline to week 16 (Table

At baseline, no significant differences were present among the

VOLUME 23 | NUMBER 2 | MARCH 2009 |

Periodized Exercise Rehabilitation for Chronic Nonspecific Low-Back Pain Management

At baseline, week 8, and week 16, no significant differences

By the studys conclusion (week 16), the RT groups showed

V_ O2max (mlkg min )

RT = resistance training; AT = aerobic training; C =

Journal of Strength and Conditioning Research

Journal of Strength and Conditioning Research

programs (16,27). This may be a potential error in the

Periodized Exercise Rehabilitation for Chronic Nonspecific Low-Back Pain Management

TABLE 6. Pain, disability, and quality of life.

RT = resistance training; AT = aerobic training; C =

(resistance) was increased. This is a relatively typical practice

stabilizers because free-weight exercises are generally

Journal of Strength and Conditioning Research

Journal of Strength and Conditioning Research

5. Bouchard, C, Shephard, RJ, and Stephens, T. Physical Activity, Fitness,

training on hormonal response patterns in younger vs. older men.

6. Brazier, JE, Harper, R, Jones, NM, OCathain, A, Thomas, KJ,

23. Kraemer, WJ, Hakkinen, K, Triplett-McBride, NT, Fry, AC, Koziris,

7. Charette, SL, McEvoy, L, Pyka, G, Snow-Harter, C, Guido, D,

24. Kuukkanen, T, Malkia, E, Kautiainen, H, and Pohjolainen, T.

9. Donchin, M, Woolf, O, Kaplan, L, and Floman, Y. Secondary

25. Lacey, R, Noels, A, Barden, J, Sharpe, D, Phenix, T, Martin, R, and

11. Godin, G, Jobin, J, and Bouillon, J. Assessment of leisure time

27. Mannion, AF, Muntener, M, Taimela, S, and Dvorak, J. A

12. Hakkinen, A, Hakkinen, K, Hannonen, P, and Alen, M. Strength

28. Noels, A, Lacey, R, Barden, J, Sharpe, D, Phenix, T, Martin, R, and