THE EFFECT OF CORE STABILITY EXERCISES ON VARIATIONS

IN ACCELERATION OF TRUNK MOVEMENT, PAIN, AND

DISABILITY DURING AN EPISODE OF ACUTE NONSPECIFIC
LOW BACK PAIN: A PILOT CLINICAL TRIAL
Augustine Aluko, PhD, a Lorraine DeSouza, PhD, b and Janet Peacock, PhD c

ABSTRACT

Objective: The purpose of this preliminary study was demonstrate if it was feasible to evaluate variations in
acceleration of trunk movement, pain, and disability during an episode of acute nonspecific low back pain comparing
regular trunk exercises to regular exercises in addition to core stability exercises.
Methods: A pilot randomized controlled trial was used to evaluate 33 participants recruited from a National Health
Service physiotherapy musculoskeletal provider in the London district of Hillingdon. Participants were allocated to
2 groups; a regular exercise group (male, 2; female, 15) with a mean (SD) age of 35.8 (9.1) years and intervention
group (male, 3; female, 13) with a mean (SD) age of 36.2 (9.8) years. The regular exercise group received exercise
that consisted of a core stability class including both specific and global trunk exercises. The intervention group,
in addition to these core exercises, received further instruction on 8 specific stabilization muscles involving the
transversus abdominis and the lumbar multifidus. Trunk sagittal acceleration, pain, and disability were measured using
a Lumbar Motion Monitor, pain visual analog scale, and Roland Morris Disability Questionnaire, respectively.
Measures were taken at baseline, 3 and 6 weeks, and a 3-month follow-up. Multiple regression with adjustment
for baseline value was used to analyze each outcome. All outcomes were log transformed to correct skewness and
so presented as ratio of geometric means with 95% confidence interval.
Results: Differences in mean trunk sagittal acceleration between the regular exercise and intervention groups was
not statistically significant at any time point (ratio of means [95% confidence interval]: 3 weeks 1.2 [0.9-1.6], P = .2; 6
weeks 1.1 [0.8-1.5], P = .7; 3 months: 1.2 [0.8-1.9], P = .9). Similarly, the effects on neither pain score nor disability
score were significant (pain score: 3 weeks 1.3 [0.8-2.2], P = .3); 6 weeks 1.2 [0.7-2.0], P = .6; 3 months 1.0 [0.5-1.9],
P = 1.0); disability score: 6 weeks 1.0 [0.7-1.5], P = 1.0; 3 months 1.3 [0.8-1.9], P = .3). Outcome measures for
both groups improved over time.
Conclusions: This pilot study demonstrated that a study of this nature is feasible. Both the regular exercise and the
intervention groups demonstrated improvements in mean trunk sagittal acceleration at 3, 6, and 12 weeks. The
preliminary findings showed that evidence was inconclusive for the beneficial effect of adding specific core stability
exercises for acute low back pain. The results of this study demonstrated an increase in acceleration accompanied by
a reduction in pain, which may suggest that acute nonspecific low back pain may induce the pain-spasm-pain model
rather than the pain adaptation model. (J Manipulative Physiol Ther 2013;36:497-504.e3)
Key Indexing Terms: Low Back Pain; Exercise; Biomechanics

a
Lecturer in Physiotherapy, Centre for Research and Rehabil-
itation, School of Sciences and Social Care, Brunel University,
London, UK.
b
Head of School and Professor of Rehabilitation, Centre for
Research and Rehabilitation, School of Sciences and Social Care,
Brunel University, London, UK.
c
Professor of Medical Statistics, Department of Primary Care
and Public Health Sciences, Kings College London, London, UK.
Submit requests for reprints to: Augustine Aluko, PhD,
Lecturer in Physiotherapy, Timberdown Ecchinswell, Nr New-
bury, Berkshire RG20 4UH, UK (e-mail: toks@askaphysio.com).
Paper submitted July 2, 2012; in revised form December 11,
2012; accepted December 27, 2012.
0161-4754/$36.00
Copyright © 2013 by National University of Health Sciences.
http://dx.doi.org/10.1016/j.jmpt.2012.12.012

497
498 Aluko et al
Core Stability Exercises and Low Back Pain
he “core” of the torso is described as the lum-
T bopelvic region, and it has been suggested that
exercises to facilitate integrity within musculature
in this area improve spinal segment stability. 1,2 However,
there is no clinically recognized definition of core stability
exercises (CSEs) and therefore no standardized recommen-
dation for any specific grouping of exercises. 3
The belief systems that underpin the current use of
CSEs as a treatment of conditions such as nonspecific
mechanical low back pain (NSLBP) suggests that focus
should be on the lumbar multifidus and transversus abdo-
minus muscles. 4 Indeed, depending on the frequency of
the exercises an increase in the cross-sectional area of the
lumbar multifidus as a direct result of CSE can be dem-
onstrated within 6 weeks. 5
Earlier work suggests that NSLBP is correlated to poor
lumbar segment stability, 6 and thus, CSEs have become a
popular choice of intervention for its treatment. 1,2 Core
stability exercises are said to assist in the activation of the
deep fibers of the lumbar multifidus through low loaded
isometric activity. 4,3 However, their overall effectiveness
remains uncertain. 7,8
The effectiveness of CSEs in the management of chronic
NSLBP is ambiguous because the effects may not be more
than that of other methods of management involving
activity. 8 However, there is paucity of literature to evaluate
its effect during an acute episode of NSLBP. This may be
because it is assumed that the effects of stabilization
exercises in enhancing neuromuscular control and rectify-
ing dysfunction 9-11 may not be required during an acute
phase of low back pain (LBP). This assertion is further
compounded by the belief that most episodes of LBP
resolve within 3 months in 90% of cases 12 and persistent
back pain will resolve by the sixth week after onset. 13,14
However, there is increasing evidence to suggest that
although NSLBP as a symptom may resolve, there may
remain unresolved biomechanical indicators for poor
lumbar function, 15,16 which may result in further lumbar
instability. It is purported that CSEs have an influence on
these indicators.
A recent systematic review of stabilization exercises as
an intervention for LBP 8 based the findings on outcomes
mainly associated with measures of either pain or disabil-
ity. The tools used were the visual analog scale (VAS) or
McGill pain questionnaire and questionnaires such as the
Oswestry Disability Index or Roland Morris Disability
Questionnaire (RMDQ), respectively. The VAS is reliable
and valid as an outcome measure, 17 especially with LBP 18;
however, the reliability of the score depends on the rigor
of the protocol to ensure that recall bias 19 is minimized.
Furthermore, the RMDQ is regarded to be the preferable
measure of disability 20,21 and is both valid and reliable. 22
In contrast, the Oswestry Disability Index has low internal
consistency (Cronbach α = .77) containing a mixture of
both capacity and performance based items. 23
Journal of Manipulative and Physiological Therapeutics
October 2013
Low back pain can be quantified using instantaneous ob-
jective measures using a Lumbar Motion Monitor (LMM) 24
to evaluate 3-dimensional spinal kinematics. 25-28 It is
therefore possible to use a similar protocol as that used
within the aforementioned studies to evaluate the effec-
tiveness of CSEs minimizing the reliance upon other
measures. Therefore, this preliminary study aimed to
quantify the effect of CSEs on trunk sagittal acceleration
during an episode of acute NSLBP and offer an insight
to how stabilization exercises may influence trunk func-
tional movement.
METHODS
This study was a randomized controlled trial and re-
ceived ethical approval from the School of Health Sciences
and Social Care Ethics committee, Brunel University,
London, UK, and the Oxfordshire NREC ethics committee
(Reference No. 07/H0606/102). The participants (n = 33)
were recruited between July 2008 and June 2010 from
within a primary care musculoskeletal physiotherapy ser-
vice provider within the London Borough of Hillingdon.
This unit provided a central base of treatment for patients
across the Borough who were referred by their general
practitioners. All participants gave informed consent to
participate in the study. The study was for a 6-week period
with a 3-month follow-up.
Participants were excluded if they demonstrated evi-
dence of any of the following: degenerative conditions af-
fecting the spine, 29 diabetes, 30 pregnancy, 31 underlying
neurologic conditions, 32 active treatment of an ongoing
spinal condition, 33 active legal/compensation procedures, 34
having a history of depression, 34 having a history of mul-
tiple recurrent episodes of LBP, 34 and involvement in other
research studies. 35 Participants who did not have English
as their primary language were also excluded.
The participants were randomly allocated to either a
routine care (n = 17) or an intervention (n = 16) group
(Table 1). The randomization was done by a colleague
independent and blind to the study using concealed enve-
lopes within which the group description was randomly
placed within them. The envelopes were numbered se-
quentially and chosen by the participants in the order in
which they were recruited.
All participants were referred for treatment of an onset
of acute NSLPB (aNSLBP) with a maximum duration of
6 weeks. Twenty-two (67%) had a previous episode of
aNSLBP. The onset of the symptoms varied within the
participants; 6 participants described the onset of their
symptoms as being sudden, 25 gradual, and 2 insidious.
All patients referred for treatment of aNSLBP within
physiotherapy service providers were assessed and subse-
quently offered a place in a “core stability” class consisting
of both specific and global trunk exercises (Appendix 1).
Journal of Manipulative and Physiological Therapeutics
Volume 36, Number 8
Table 1. Study group descriptive
Age (y), Height (cm), Weight (kg),
mean (SD) mean (SD) mean (SD)
Regular exercise group 35.8 (9.1) 167.4 (9.0) 73.3 (15.6)
(male, 2; female, 15)
Intervention (male, 3; 36.2 (9.8) 166.8 (10.6) 75.9 (18.0)
female, 13)
Participants in both groups received this protocol as
minimum intervention. The intervention group received
further instruction on 8 specific stabilization muscle
involving the transversus abdominis (TrA) and the lumbar
multifidus (LM).
Equipment
The LMM was used to evaluate trunk sagittal acceler-
ation. The LMM has been demonstrated to be a valid and
reliable 36 tool for trunk sagittal acceleration evaluation. The
reliability was repeated for a single measure (intra-class
correlation coefficient, 0.96; 95% confidence interval [CI],
0.90-0.98), 16 and laboratory calibration tests of the LMM
have demonstrated only a 2% discrepancy between actual
measurement and recorded data. 37
Core Stability Exercises
There is no formal definition of CSEs or recommenda-
tion for any specific grouping of CSEs. 3 There is also no
justification for the choice, combination of, or the number
of repetitions and frequency of the chosen exercises. 3 The
selection of exercises used in this study therefore relied on
current belief systems suggesting that the isolation of the
TrA and LM is important for trunk stability 4 (Appendix 2).
These exercises were as follows: abdominal hollowing in
prone lying, alternate straight-leg raise in supine, abdom-
inal hollowing in sitting, Crook lying–alternate heel slide,
4-point kneeling pelvic shift (side to side), trunk curl in
crook lying, pelvic tilt in sitting, and alternate knee raise
in sitting.
The exercises met suggested criteria for safety; these
included the avoidance of active hip flexion with fixed feet
positioning and pulling with the hands behind the head
and ensuring knee and hip flexion during all upper body
exercises. 38The intervention group participants were re-
quired to perform 10 repetitions of each of the above exer-
cises 3 times a day. To facilitate compliance, participants
were required to complete a compliance diary. The diary
method was chosen to avoid adding to the participants'
perceived barrier to exercise by impinging on the available
time that they have to do the exercise routine. 39
Protocol
Initial evaluation of outcome measures of trunk sagittal
acceleration (°/s 2) using the LMM, pain (mm) using a
Aluko et al 499
Core Stability Exercises and Low Back Pain
VAS comprising of a 100-mm line with no numbers, and
disability using the RMDQ was taken at the start of the
study and at 3, 6, and 12 weeks subsequently (Fig 1). Data
were collected by the researcher who was therefore not
blinded to the grouping of any of the participants. At the
initial visit, those allocated to the intervention group were
given an individual initial specific CSE instruction by the
researcher and a diary large enough to contain only 3
weeks' entry data. This ensured that the participants
within this group would have to request more sheets to
complete the following 3 weeks. At time point, the parti-
cipants in the intervention group were asked to demon-
strate the exercises to ensure that they had mastered the
routine. Care was taken to ensure that each participant felt
that he/she was given equal access to the researcher
throughout the study.
The standard LMM protocols for a 5-task evaluation 27
and a single-task evaluation 29 have been adequately
described elsewhere. This study used the single-task eval-
uation method.
The LMM protocol required the participants to perform
as many sagittal trunk flexion-extension movements as
possible for 8 seconds. The movement was executed at the
participants' preferred speed and within their preferred
range of movement. It has been demonstrated that ex-
perimental pain can alter neuromuscular responses during a
trunk flexion-extension task. 40 No encouragement verbal,
nonverbal, or otherwise was offered. Although LBP in-
creases the time for trunk muscles to reach peak force
during a contraction, 41 no warm-up exercise was performed
because the interest of the study lay within the natural
muscle recruitment process to effect functional movement
without prior warning. All trunk measurements were there-
fore also taken before each scheduled core stability class.
All participants completed the evaluation, and none
reported an exacerbation of their symptoms. The RMDQ
score was not obtained at 3 weeks.
Statistics
In the absence of a known published clinically significant
difference for the primary outcome measure of mean trunk
sagittal acceleration resulting from CSEs, it was not possible
to use a standardized calculation to determine an appropriate
sample size. The sample size was therefore derived from a
similar study previously published. 42Although the partici-
pants were randomly allocated as they were recruited and
blinded to the study, it was not possible to blind the assess-
ment process.
Analysis
The outcome data were analyzed using multiple regres-
sion analysis where the baseline value was included as a
covariate for each analysis. Because all outcomes were
500 Aluko et al
Core Stability Exercises and Low Back Pain
Fig 1. Study flow diagram. LMM, Lumbar Motion Monitor; RMDQ, Roland Morris Disability Questionnaire; VAS, visual analog scale.
skew, data were log transformed, and therefore, results are
presented as the ratio geometric means with 95% CI. These
are interpreted as showing the percentage difference in
mean value between the 2 groups; for example, a ratio of
1.20 for the intervention/regular exercise group indicates
that the intervention group was on average 20% greater than
the regular exercise group.
An intention-to-treat analysis 43 was used with missing
data replaced with the Last Observation Carried Forward 44
for incomplete data sets. This process was deemed appro-
priate for this study because the trend of the raw data dem-
onstrated either a sequential improvement or status quo in
the outcome measures within both groups of participants.
All data analyses were conducted using SPSS (V. 15;
SPSS, Chicago, IL).
RESULTS
Data were collected from both the regular exercise
group, which had a mean (SD) age of 35.8 (9.1) years, with
a mean (SD) height of 167.4 (9.0) cm and a mean (SD)
weight of 73.3 (15.6) kg, and the intervention group, which
Journal of Manipulative and Physiological Therapeutics
October 2013
had a mean (SD) age of 36.2 (9.8) years with a mean (SD)
height of 166.8 (10.6) cm and mean (SD) weight of 75.9
(18.0) kg (Table 1). The data required logarithm transfor-
mation and further analysis by regression to determine
differences between the groups (Table 2).
Within 3 weeks, improvement in mean trunk sagittal
acceleration in the intervention group was 20% greater
than in the regular exercise group, after adjusting for
baseline, but this was not statistically significant (95% CI,
0.9-1.6; P = .2) (Table 2). Similar improvements of 10%
and 20%, respectively, could be seen at 6 weeks (95% CI,
0.8-1.5; P = .7) and 3 months (95% CI, 0.8-1.9; P = .9).
These results were not statistically significant (Table 2).
Mean pain scores were similar in both groups at each
stage of the study; the differences in mean pain scores
between the groups adjusted for baseline were not statis-
tically significant at 3 weeks (30%; 95% CI, 0.8-2.2; P =
.3), 6 weeks (20%; 95% CI, 0.7-2.0; P = .6), or 3 months
(0%; 95% CI, 0.5-1.9; P = 1.0) (Table 2). Mean pain score
analysis between 3 months and 6 weeks was not possible
because of the effect of missing data and the small sample
size. The differences in disability scores between the groups
adjusted for baseline were also statistically nonsignificant
Journal of Manipulative and Physiological Therapeutics Aluko et al 501
Volume 36, Number 8 Core Stability Exercises and Low Back Pain

at 6 weeks (0%; 95% CI, 0.7-1.5; P = 1.0) and 3 months

1.0

.3
P

–
–
(30%; 95% CI, 0.8-1.9; P = .3) (Table 2).
Intervention
(n = 16)

7.4 (5.4)

6.8 (5.1)
8.6 (5.0)
DISCUSSION
Disability, mean (SD)
(RMDQ 0-24)

Both the regular exercise and the intervention groups

–

demonstrated improvements in mean trunk sagittal accel-

eration of 2.8% and 29.2%, respectively, at 3 weeks; 15.1%
Regular exercise

and 29.4%, respectively, at 6 weeks; and 13% and 37%,

1.0 (0.7-1.5)

1.3 (0.8-1.9)
(n = 17)

respectively, at 12 weeks. The increase in cross-sectional

9.4 (5.8)

8.4 (6.2)
10.5 (5.0)

area of the TrA and LM shown to increase within a 6-week

period 5 may therefore be directly related to improvement
–
–

in mean trunk sagittal acceleration. Although the results

suggest that the improvement demonstrated is not
1.0
.3

.6

statistically significant, this size of effect is of clinical

P

significance and so, if shown to be conclusively true,

would be important. Low back pain impedes trunk
Intervention

31.8 (23.6)

25.9 (23.2)
36.4 (23.2)

26.0 (22.0)

acceleration 15,16; early intervention may therefore be

(n = 16)
Pain score (mm), mean (SD)

productive in influencing the natural course of aNSLBP.

The improvement in mean sagittal acceleration was
(VAS 1-100)

maintained within the intervention group at 12 weeks,

suggesting that CSE may not only improve trunk sagittal
Regular exercise

acceleration but also help to maintain it. This would have

1.3 (0.8-2.2)

1.2 (0.7-2.0)

1.0 (0.5-1.9)
(n = 17)

considerable clinical significance if CSEs were conclu-

26.7 (26.0)

27.1 (26.7)
31.4 (22.0)

25.3 (23.5)

sively shown to have an integral role in reducing the risk of

aNSLBP becoming chronic.
Good posture is an important factor in managing, pre-
venting, or facilitating recovery from an episode of LBP.
.2

.7

.9

However, the actual detail of the mechanics of posture is

P

largely ignored. The range of lumbar lordosis 45 plays an

important role in this because it alters according to pos-
174.5 (133.7)

225.5 (163.4)

225.8 (178.0)

239.1 (177.5)
Intervention

ture. 46,47 The range of lumbar lordosis is suggested to be

(n = 16)
acceleration (°/s2), mean (SD)

directly proportional to the changes in acceleration. 45

Thus, improved acceleration will increase the available
RMDQ, Roland Morris Disability Questionnaire; VAS, visual analog scale.

range by which the lumbar lordosis is able to accommodate

Sagittal

axial compressive forces. These results suggest that CSEs

Regular exercise

may be able to facilitate this mechanism. However, this

1.2 (0.9-1.6)

1.1 (0.8-1.5)

1.2 (0.8-1.9)

would not be true if there was structural trunk stiffness

(n = 17)
166.0 (110.2)

170.7 (95.5)

191.1 (99.1)

187.5 (99.5)

caused by underlying natural pathology such as natural

degenerative change. 48,3 It is these underlying natural
pathologies that may have influenced the results of
previous studies and subsequent systematic reviews to
evaluate the effectiveness of stabilization exercises.
Table 2. Results by outcome measure

Difference between groups adjusted

Difference between groups adjusted

Difference between groups adjusted

This study did not demonstrate a causal relationship

between the improvement in trunk sagittal acceleration and
for baseline at 3 mo. Ratio of
for baseline at 3 wk. Ratio of

for baseline at 6 wk. Ratio of

pain, although a negative correlation between pain and

geometric means (95% CI)

geometric means (95% CI)

geometric means (95% CI)

trunk performance has been previously reported. 45 It has

been suggested that the pain adaptation model reduces
trunk velocity 49; however, this study demonstrates an
increase. The findings of this study therefore suggest that
an NSLBP may induce the pain-spasm-pain model 50 rather
Analysis
Baseline

than the pain adaptation model because the results of this

3 mo
3 wk

6 wk

study demonstrate an increase in acceleration accompanied

by a reduction in pain. 50 Clinically, this could be very
502 Aluko et al
Core Stability Exercises and Low Back Pain
important because treatment/intervention for aNSLBP
could be more effective if it is aimed at reducing the
excitability of the α-neurons or reducing muscle spindle
activity. 51 It is possible that CSEs are able to do this
efficiently.
The sensitivity of the RMDQ in quantifying disability
may not be as high for the participants within this study
because they were not “back pain disabled”; they did not
have the pain long enough to decide that certain move-
ments caused pain unlike individuals with chronic LBP. 52
The difference in disability between the groups was
neither statistically nor clinically significant because the
difference was less than 30%. 53 However, the regular
exercise group appeared to maintain a higher mean dis-
ability score than the intervention group. This does sug-
gest that CSEs may facilitate a reduction in disability,
albeit the depth of this facilitation is not categorical. The
trend of the results was not in keeping with 2 previous
studies that demonstrated significant improvement in
disability after intervention at 6 weeks (50%) and at 3-
month (67%) and 12-month (56%) follow-up periods. 54
Another study demonstrated a 43.2% improvement after
4 weeks. 55 It may be that the rigor applied to this study
influenced the result, but this must be put in context of the
smaller sample size.
LIMITATIONS AND FUTURE RESEARCH
The small sample size was a limitation. Also, all parti-
cipants were from a wide area within the Borough, but the
participants may not have been a true reflection of aNSLBP
prevalence in the district or London in general. Further
limitations include the inability to remove all possible
sources of bias; the researcher not only collected the data
and did the analysis but also administered the first CSE
instruction. Furthermore, the study only evaluated 1 plane
of trunk movement, whereas functional trunk movement is
3 dimensional. 25 There were also limitations in that there
was no indication for how long a rest period should be
between exercises and how the exercise routine should be
distributed through the day. Also, both groups received
therapeutic exercise; thus, it may be difficult to separate the
effects of these 2 therapies or the additive effect of the CSE
to regular therapeutic exercises.
At present, it is not possible to propose a difference in
trunk sagittal acceleration below which an episode of
aNSLBP may develop. If possible such information would
be useful. Further work to investigate the changes in trunk
performance over time will also be beneficial. This infor-
mation will be useful in identifying the cohort of individuals
who may therefore benefit from early intervention of CSEs
as a preventative measure. The implications of which may
be significant for the cost of health care delivery.
The Swiss ball is an effective rehabilitative tool for
patients with LBP. 56 Further work to evaluate CSEs using
Journal of Manipulative and Physiological Therapeutics
October 2013
this rehabilitative method may provide a greater depth of
evaluation of this approach and provide greater under-
standing of trunk response to perturbation during an episode
of aNSLBP.
CONCLUSION
Trunk sagittal acceleration appears to be sensitive to an
onset of aNSLBP. The clinically meaningful sizes of effect
were observed, which, if shown to be real in a larger study,
would be important. This requires further investigation,
although improvement in trunk sagittal acceleration and
thus its performance was not conclusively demonstrated.
Similarly, although reduction in disability and pain as a
result of CSEs as an intervention may not be statistically
significant between groups, the sizes of effect observed
were clinically significant.
Practical Applications
• Both the regular exercise and intervention
groups demonstrated improvements in mean
trunk sagittal acceleration at 3, 6, and 12
weeks.
• The results of this study demonstrated an
increase in acceleration accompanied by a
reduction in pain, which may suggest that
aNSLBP may induce the pain-spasm-pain
model rather than the pain adaptation model.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
No funding sources or conflicts of interest were reported
for this study.
REFERENCES
1. Willardson JM. Core stability training for healthy athletes: a
different paradigm for fitness professionals. Strength Cond J
2007;29:42-9.
2. Willardson JM. Core stability training: applications to sports
conditioning programs. J Strength Cond Res 2007;21:979.
3. Standaert CJ, Weinstein SM, Rumpeltes J. Evidence-informed
management of chronic low back pain with lumbar stabiliza-
tion exercises. Spine J 2008;8:114.
4. MacDonald DA, Moseley GL, Hodges PW. The lumbar
multifidus: does the evidence support clinical beliefs. Man
Ther 2006;11:254.
5. Sokunbi O, Watt P, Moore A. A randomized controlled trial
(RCT) on the effects of frequency of application of spinal
stabilization exercises on multifidus cross sectional area
Journal of Manipulative and Physiological Therapeutics
Volume 36, Number 8
(MFCSA) in participants with chronic low back pain.
Physiother Singapore 2008;11:9-16.
6. Panjabi MM. Lumbar spine instability: a biochemical
challenge. Curr Orthop 1994;8:100.
7. Standaert CJ, Herring SA. Expert opinion and controversies
in musculoskeletal and sports medicine: core stabilization as
a treatment for low back pain. Arch Phys Med Rehabil 2007;
88:1734.
8. May S, Johnson R. Stabilisation exercises for low back pain: a
systematic review. Physiotherapy 2008;94:179.
9. Richardson C, Jull G, Hodges P, Hides J. Therapeutic exer-
cises for spinal segmental stabilisation in low back pain.
Edinburgh: Churchill Livinstone; 1999.
10. Norris CM. Back stability. Champaign: Human Kinetics; 2000.
11. Mcgill S. Low back disorders. Evidence-based prevention and
rehabilitation. Champaign: Human Kinetics; 2002.
12. Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E,
Silman AJ. Outcome of low back pain in general practice. Br
MedJ 1998;316:1356.
13. Jayson MIV. Back pain. BMJ 1996;313:355.
14. BACKCARE. Back Facts. 2007. Available at: http://www.
backpain.org/b_pages/backfacts-2007.php. Accessed March
21, 2007.
15. Marras WS, Lewis EK, Ferguson SA, Parnianpour M.
Impairment magnification during dynamic trunk motions.
Spine 2000;25:587-95.
16. Aluko AA, Desouza LH, Peacock J. Evaluation of trunk
acceleration in healthy individuals with low back pain. Int J
Ther Rehabil 2011;18:18.
17. Crossley KM, Bennell KL, Cowan SM, Green S. Analysis of
outcome measures for persons with patellofemoral pain:
which are reliable and valid? Arch Phys Med Rehabil 2004;
85:815.
18. Olaogun MOB, Adedoyin RA, Ikem IC, Anifaloba OR.
Reliability of rating low back pain with visual analogue scale
and a sematic differential scale. Physiother Theory Pract 2004;
20:135.
19. Chouinard E, Walter S. Recall bias in case-control studies: An
empirical analysis and theoretical framework. J Clin Epide-
miol 1995;48:245-54.
20. Deyo RA, Battie M, Beurskens AJHM, et al. Outcome mea-
sures for low back pain research: a proposal for standardized
use. Spine 1998;23:2003-13.
21. Boonstra AM, Schiphorst Preuper HR, Reneman MF,
Posthumus JB, Stewart RE. Reliability and validity of the
visual analogue scale for disability in patients with
chronic musculoskeletal pain. Int J Rehabil Res 2008;31:
165.
22. Roland M, Morris R. A study of the natural history of back
pain. Part 1: development of a reliable and sensitive measure
of disability in low back pain. Spine 1983;8:14.
23. Peat G. PPA recommendations for low back pain related
functional limitation outcome measures. 2nd ed. London: The
Chartered Society of Physiotherapy; 2004. p. 1-27.
24. Marras WS, Mirka GA. Electromyographic studies of the
lumbar trunk musculature during the generation of low level
trunk acceleration. J Orthop Res 1993;11:811.
25. Marras WS, Wongsam PE. Flexibility and velocity of the
normal and impaired lumbar spine. Arch Phys Med Rehabil
1986;67:213.
26. Kroemer KHE, Marras WS, Mcglothlin DR, Nordin M.
Towards understanding human dynamic motor performance.
Ind Ergon J 1990;6:199.
27. Marras WS, Ferguson SA, Simon SR. Three dimensional
dynamic motor performance of the normal trunk. Int J Ind
Ergon 1990;6:211.
Aluko et al 503
Core Stability Exercises and Low Back Pain
28. Marras WS. Quantification of motion characteristics in low
back disorders. J Rehabil Res Dev 1996;33:186.
29. Gruber HE, Norton HJ, Sun Y, Hanley EN. Crystal deposits in
the human intervertebral disc: implications for disc degener-
ation. Spine J 2007;7:444-50.
30. Bohannon RW. Muscle strength impairments in diabetes
mellitus: a brief review. Clin Exerc Physiol 2000;2:185-8.
31. Kerr R, Grahame R, editors. Hypermobility syndrome:
recognition and management for physiotherapists. 1st ed.
London: Butterworth Heinemann; 2003. p. 67-105.
32. Wei SH, Jong YJ, Chang YJ. Ulnar nerve conduction velocity
in injured baseball pitchers. Arch Phys Med Rehabil 2005;86:
21-5.
33. Altman DG. Practical statistics for medical research. 1st ed.
London: Chapman & Hall; 1991.
34. Standaert CJ, Weinstein SM, Rumpeltes J. Evidence-informed
management of chronic low back pain with lumbar stabilisa-
tion exercises. Spine J 2008;8:114.
35. Hicks CM. Practical research methods for physiotherapists. .
1st ed. London: Churchill Livingstone; 1998.
36. Ferguson SA, Marras WS. Revised protocol for the kinetic
assessment of impairment. Spine J 2004;4:163.
37. Aluko AA. The effect of core stability exercises (CSE) on
trunk sagittal acceleration. United Kingdom: PhD. Brunel
University; 2011.
38. Monfort-Pañego M, Vera-Garcia FJ, Sānchez-Zuriaga D,
Sarti-Martinez M A. Electromyographic studies in abdominal
exercises: a literature synthesis. J Manipulative Physiol Ther
2009;32:232-44.
39. Sluijs EM, Kok GJ, Van Der Zee J. Correlates of exercise
compliance in physical therapy. Phys Ther 1993;73:771.
40. Tētreau C, Dubois JD, Pichē M, Descarreaux M. Modulation
of pain-induced neuromuscular trunk responses by pain
expectations: a single group study. J Manipulative Physiol
Ther 2012;35:L636-44.
41. Descreaux M, Lalonde C, Normand MC. Isometric force
parameters and trunk muscle recruitment strategies in a popu-
lation with low back pain. J Manipulative Physiol Ther 2007;
30:91-7.
42. Webber SC, Kriellaars DJ. The effects of stabilisation ins-
truction on lumbar acceleration. Clin Biomech 2004;19:777.
43. Altman DG. Practical statistics for medical research. 1st ed.
London: Chapman & Hall; 1991.
44. Howell D. Statistical methods tor psychology. 3rd ed. Boston,
MA: PWS Kent; 1992.
45. Cox ME, Asselin S, Gracovetsky SA, et al. Relationship
between functional evaluation measures and self-assessment
in non-acute low back pain. Spine 2000;25:1817.
46. Knutson GA. Incidence of foot rotation, pelvic crest un-
levelling, and supine leg length alignment asymmetry and
their relationship to self-reported back pain. J Manipulative
Physiol Ther 2002;25:110.
47. Al-Eisa E, Egan D, Deluzio K, Wassersug R. Effects of
pelvicasymmetry and low back pain on trunk kinema-
tics during sitting: a comparison with standing. Spine 2006;
31:135.
48. Gruber HE, Norton HJ, Sun Y, Hanley EN. Crystal deposits in
the human intervertebral disc: implications for disc degener-
ation. Spine J 2007;7:444-50.
49. Van Tulder MW, Malmivaara AV, Esmail R, Koes BW.
Exercise therapy for low back pain: a systematic review within
the framework of the Cochrane Collaboration Back Pain
Review Group. Spine 2000;25:2784.
50. Van Dieen JH, Cholewicki J, Radebold A. Trunk muscle
recruitment patterns in patients with low back pain enhance
the stability of the lumbar spine. Spine 2003;28:834.
504 Aluko et al
Core Stability Exercises and Low Back Pain
51. Johansson H, Sojka P. Pathophysiological mechanisms
involved in genesis and spread of muscular tension in occu-
pational muscle pain and in chronic musculoskeletal pain
syndromes: a hypothesis. Med Hypotheses 1991;35:196.
52. Beurskens AJHM, De Vet HCW, Kök AJA. Responsiveness
of functional status in low back pain: a comparison of different
instruments. Pain 1996;65:71-6.
53. Jordan K, Dunn KM, Lewis M, Croft P. A minimal clinically
important difference was derived for the Roland-Morris Dis-
ability Questionnaire for low back pain. J Clin Epidemiol
2006;59:45-52.
Journal of Manipulative and Physiological Therapeutics
October 2013
54. Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I. Stabiliz-
ing training compared with manual treatment in sub-acute and
chronic low-back pain. Man Ther 2003;8:233-41.
55. Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Erhard RE.
Identifying subgroups of patients with acute/subacute “non-
specific” low back pain. Results of a randomised clinical trial.
Spine 2006;31:623.
56. Marshall PW, Murphy BA. Evaluation of functional and
neuromuscular changes after exercise rehabilitation for low
back pain using a Swiss ball: a pilot study. J Manipulative
Physiol Ther 2006;29:550-60.
Journal of Manipulative and Physiological Therapeutics Aluko et al 504.e1
Volume 36, Number x Core Stability Exercises and Low Back Pain

APPENDIX 1. REGULAR EXERCISE GROUP EXERCISES

Reprinted by permission from Norris CM. Back stability. hollowing sitting and abdominal hollowing lying), 110
CD-ROM, release 1.0. Champaign, IL: Human Kinetics; (straight leg raise), 126 (trunk curl), 157 (pelvic tilt
2002. Human Kinetics, 1607 North Market Street, PO Box reeducation, sitting), 170 (heel slide), 174 (4-point pelvic
5076, Champaign, IL 61825-5076; pages 85 (abdominal shift), and 183 (sitting knee raise).
504.e2 Aluko et al Journal of Manipulative and Physiological Therapeutics
Core Stability Exercises and Low Back Pain October 2013
Journal of Manipulative and Physiological Therapeutics Aluko et al 504.e3
Volume 36, Number 8 Core Stability Exercises and Low Back Pain

APPENDIX 2. INTERVENTION GROUP EXERCISES: CSES

Reprinted with permission from PhysioTools Ltd.
Viinikankatu 1 C, FIN-33100 Tampere, Finland.