Journal of International Medical

Research
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Pelvic floor muscle exercise for chronic low back pain

Xia Bi, Jiangxia Zhao, Lei Zhao, Zhihao Liu, Jinming Zhang, Dan Sun, Lei Song and Yun Xia
Journal of International Medical Research 2013 41: 146 originally published online 23 January
2013
DOI: 10.1177/0300060513475383
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Research Note

Pelvic floor muscle exercise

for chronic low back pain

Journal of International Medical Research

41(1) 146152
! The Author(s) 2013
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0300060513475383
imr.sagepub.com

Xia Bi,1 Jiangxia Zhao,2 Lei Zhao,1 Zhihao Liu,1

Jinming Zhang,1 Dan Sun,1 Lei Song1 and
Yun Xia1

Abstract
Objective: To assess the effect of pelvic floor muscle exercise in patients with chronic low
back pain.
Methods: Adults (aged 18 years) with chronic low back pain (with or without radiculopathy)
were randomized to undergo either routine treatment (ultrasonography, short wave diathermy
and lumbar strengthening exercises; control group) or routine treatment with pelvic floor
exercises (intervention group) for 24 weeks. Pain, disability (Oswestry Disability Index [ODI]
score) and trunk muscle function were assessed at baseline and after completion of treatment.
Results: The study included 47 patients (control group n 24; intervention group n 23). Pain
severity and ODI scores were significantly lower in the intervention group than in the control
group after 24 weeks. There were no significant between-group differences in trunk muscle
function.
Conclusion: Pelvic floor exercise in combination with routine treatment provides significant
benefits in terms of pain relief and disability over routine treatment alone.

Keywords
Low back pain, pain, pelvic floor muscles, rehabilitation
Date received: 28 August 2012; accepted: 8 September 2012

dysfunction is associated with the development of low back pain.9,10 The pelvic oor is a

Introduction
Low back pain is common worldwide, with
6080% of people aected at some time in
their lives.13 It has a major impact on health
and health-related quality of life, diminishing the capacity for standing, walking and
sitting.4,5
Exercise is commonly used in the management of chronic low back pain, in particular
the training of core stabilizing muscles including pelvic oor muscle.68 Pelvic oor muscle

Department of Rehabilitation Medicine, Pudong New

District Gongli Hospital, Shanghai, China
2
Department of Medical Services, Pudong New District
Gongli Hospital, Shanghai, China
Corresponding author:
Dr Jiangxia Zhao, Department of Medical Services, Pudong
New District Gongli Hospital, 219 Miaopu Road, Shanghai
200135, China.
Email: bxxb1123@163.com

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147

Bi et al.

hammock of muscles that connect the pubis to

the tailbone and ischial tuberosities.11 Pelvic
oor muscle insuciency can occur as a result
of pain, poor movement patterns, trauma,
surgery or childbirth.9 These muscle imbalances do not recover spontaneously, and can
lead to low back, pelvis and/or hip pain.10
The pelvic oor is an important component of the core stabilizing muscles, but
many physical therapists and patients with
low back pain neglect to train pelvic oor
muscles.12 In addition, there is little evidence
that combined routine treatment (ultrasonography, short wave diathermy and lumbar
strengthening exercises) and pelvic oor
muscle exercise oers any advantage over
routine treatment alone. The present study
assessed the eects of routine treatment with
or without pelvic oor muscle exercise in
patients with chronic low back pain. The
eects of both treatments on self-reported
pain levels and trunk muscle strength were
evaluated.

Patients and methods

Study Population
This double-blind, randomized, controlled
trial enrolled patients aged 1860 years, with
chronic, nonspecic low back pain for 3
months, with or without radiculopathy.
Patients
were
recruited
from
the
Department of Rehabilitation Medicine,
Pudong New District Gongli Hospital,
Shanghai, China, between August 2010
and May 2012. Exclusion criteria were: (i)
continuous pain >8 on a visual analogue
scale (VAS; where 0 represented no pain and
10 represented the worst pain possible);13 (ii)
previous attendance at any structured pelvic
oor muscle training programme; (iii) previous spinal or pelvic surgery; (iv) progressive neurological decit, structural anomaly,
acute infection, ongoing back pain treatment by other health care providers, severe
instability, severe osteoporosis, and severe
cardiovascular or metabolic disease.

All participants completed a questionnaire including demographic data, medical

history, Oswestry Disability Index (ODI)
score14 and back pain. Patients were randomized to the intervention or control group
by an independent collaborator within
2 days after enrolment, using opaque
closed envelopes.
The study was approved by the Ethics
Committee of Pudong New District Gongli
Hospital, and all patients provided written
informed consent prior to enrolment.

Treatment
All patients followed a 24-week treatment
plan of routine treatment, with (intervention
group) or without (control group) additional pelvic oor exercises. Both treatment
programmes were led by registered physical
therapists.
Routine treatment comprised ultrasonography (1 MHz continuous at 1.2 W/cm2
for 5 min), short-wave diathermy (continuous mode for 15 min) and lumbar
strengthening exercises (10 repetitions each
of prone leg elevation, prone chest elevation
and supine bridging).15 Routine treatment
was performed three times per week for
24 weeks.
The pelvic oor muscle exercise programme was based on contraction of the
pelvic oor muscles for 6 s followed by rest
for 6 s, resulting in 5 contraction cycles/min.
The number of contraction cycles was
increased over the 24-week treatment
period: week 1, 25 cycles/day (5 min total);
week 2, 50 cycles/day (10 min total); week 3,
75 cycles/day (15 min total); weeks 424,
100 cycles/day (20 min total).16

Outcome Measures
Outcome measures were assessed at baseline
and after the 24-week treatment period. All
assessments were performed by three independent, experienced physical therapists

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Journal of International Medical Research 41(1)

who were not employed at the participating
rehabilitation centre, had no contact with
patients during the treatment period and
were blinded to treatment allocations. All
assessments took place at Department of
Rehabilitation Medicine, Pudong New
District Gongli Hospital, Shanghai, China.
Outcome measures included: (i) average
pain intensity over the previous week,
assessed via VAS;13 (ii) disability, assessed
via ODI scoring;14 (iii) static muscle endurance (length of time the patient was able to
maintain an unsupported upper body in the
prone [extension] and supine positions [exion]); (iv) dynamic muscle endurance
(number of sit-ups [exions] and prone
trunk extensions performed in 1 min).17

Statistical Analyses
Data were expressed as mean  SD.
Dierences between groups at baseline
were analysed using independent samples
t-test and the 2-test. The eect of treatment
was assessed via two-way analysis of variance (group  time). Statistical analyses
were performed with SPSS software, version 17.0 (SPSS Inc, Chicago, IL, USA) for
Windows and Microsoft Excel 2003
(Microsoft, Redmond, WA, USA). A
P-value <0.05 was considered statistically
signicant.

Results
In total, 50 patients were randomized
(n 25 per group). A ow chart indicating
the recruitment and treatment allocations of
the patients is shown in Figure 1. At the end
of the 24-week treatment period, outcome
data were available for 23/25 patients in the
intervention group and 24/25 in the control
group. Baseline demographic and clinical
characteristics of the patients are shown
in Table 1. There were no statistically

148
signicant between-group dierences in
any characteristic at baseline.
Outcome data at the end of the 24-week
treatment period are shown in Table 2. Pain
severity and ODI scores were signicantly
lower in the intervention group than in the
control group (P 0.045 and P 0.034
respectively, Table 2). There were no signicant between-group dierences in static or
dynamic endurance.

Discussion
Pelvic oor muscles make up a large part of
the bodys core,18 which is the foundation
for all movement, balance, stability and
exibility.19 The pelvic oor muscle exercise
protocol used in the present study was
designed to coactivate supercial and deep
core muscles, and resulted in signicantly
better improvements in pain and ODI score
compared with routine treatment alone.
Back function parameters were improved
over baseline in both treatment groups, with
no signicant between-group dierences.
These results are consistent with the ndings
of others, who demonstrated the superiority
of a core strengthening programme to
simple strengthening exercises for chronic
low back pain.7 Others have suggested,
however, that core stability exercises do
not provide any benet over conventional
physiotherapy exercises in terms of pain or
disability reduction.20 A pelvic oor muscle
exercise programme comprising 6 contraction cycles/day for 12 weeks was found to
provide no additional improvement in pain
or ODI score compared with routine treatment. 21 The more intense training and
longer treatment period (a minimum of 25
contraction cycles/day for 24 weeks) may
explain the signicant improvements in pain
and disability seen in the present study.
Improving the biomechanical characteristics
of muscles in patients with low back pain
may require long-term pelvic oor muscle

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149

Bi et al.

Assessed for eligibility n = 53

Excluded n = 3
n = 2 did not meet inclusion criteria
n = 1 scheduled work incompatibility

Baseline assessment n = 50

Randomized n = 50

Intervention group n = 25

Control group n = 25

Withdrew n = 1
Family problem n = 1

Assessed at 24 weeks n = 23

Lost to follow-up n = 1

Assessed at 24 weeks n = 24

Figure 1. Flow chart indicating recruitment, randomization and follow-up of patients with chronic low back
pain included in a study to compare the effects of 24 weeks of routine treatment (ultrasonography, short wave
diathermy and lumbar strengthening exercises; control group) or combination routine treatment and pelvic
floor muscle exercise (intervention group) on back pain, disability and function.

training. Studies have shown that a training

period of 20 weeks is required for patients
with persistent pelvic girdle pain.22
The current study had several limitations.
First, this was a single-centre study and the
sample size was too small to draw any rm
conclusions. Secondly, some patients did not
perform the pelvic oor muscle exercises
correctly. Finally, as the study population
included patients with nonspecic low back

pain, it is not possible to generalize these

ndings to those with low back pain of
specic cause.
In conclusion, pelvic oor exercises in
combination with routine treatment provide
signicant benets in terms of pain relief and
disability over routine treatment alone.
Further, larger-scale studies with long-term
follow-up are required before these ndings
can be applied to a wider patient cohort.

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Journal of International Medical Research 41(1)

150

Table 1. Baseline demographic and clinical characteristics of patients with chronic low back pain included in
a study to compare the effects of 24 weeks of routine treatment (ultrasonography, short wave diathermy and
lumbar strengthening exercises; control group) or combination routine treatment and pelvic floor muscle
exercise (intervention group) on back pain, disability and function.
Characteristic

Control group n 24

Intervention group n 23

Sex, males/females
Age, years
Height, cm
Body weight, kg
BMI, kg/m2
Duration of back pain, months
Pain severitya
ODI score
Trunk muscle function
Static endurance, s
Flexion
Extension
Dynamic endurance, no. of repetitions
Flexion
Extension

13/11
30.87  2.81
170.59  6.74
61.41  5.83
22.13  2.58
8.38  2.96
5.22  2.64
31.27  7.85

13/10
29.08  2.68
168.57  6.53
61.55  5.89
21.01  2.03
7.34  2.24
5.35  3.57
32.57  6.25

49.71  18.33
58.34  17.18

43.69  20.13
53.13  18.25

36.43  11.45
17.72  7.11

36.21  13.86
18.14  8.49

Data presented as n of patients or mean  SD.

a
Assessed via visual analogue scale: 0, no pain; 10, worst pain possible.13
BMI, body mass index; ODI, Oswestry disability index.14
No statistically significant between-group differences (P  0.05; Students t-test or 2-test).

Table 2. Back pain, disability and functional parameters in patients with chronic low back pain after
completion of a 24-week treatment programme, comprising routine treatment (ultrasonography, short wave
diathermy and lumbar strengthening exercises; control group) or combination routine treatment and pelvic
floor muscle exercise (intervention group).
Parameter
Pain severityb
ODI score
Trunk muscle function
Static endurance, s
Flexion
Extension
Dynamic endurance, no. of repetitions
Flexion
Extension

Control group
n 24

Intervention group
n 23

Statistical
significancea

2.97  2.27
19.57  9.83

2.08  1.63
14.87  7.44

P 0.045
P 0.034

69.87  26.25
76.85  27.18

73.08  30.38
84.62  31.29

NS
NS

52.83  15.77
20.52  8.40

56.81  21.11
25.96  12.24

NS
NS

Data presented as mean  SD.

ODI, Oswestry disability index;14 NS, not statistically significant (P  0.05).
a
Two-way analysis of variance.
b
Assessed via visual analogue scale: 0, no pain; 10, worst pain possible.13

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Bi et al.

Declaration of Conflicting Interest

The authors declare that there are no conicts of
interest.

Funding
This research was supported by grants from the
Science and Technology Development Fund of
Shanghai Pudong (PKJ2008-Y39), the Program
of Shanghai Pudong Subject Chief Scientist
(PWRd2010-06)
and
the
Science
and
Technology Development Fund of Shanghai
Pudong (PKJ2011-Y05).

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