E ffe ct of Lum bar S t abiliz ation E x erc is e on S pin al In s t ability in P atient s W ith Low B ac k P ain : A Lite rature Re v ie w

Intr oduction

Low back pain (LBP ) is one of the m ost comm on and costly m edical pr oblem s in m odern indu strialized societies (Coste et al, 1991; Gr av es et al, 1990; O' Sulliv an , 2000).

Back pain is the m ost comm on complaint seen by phy sical ther apist ; it is also the symptom m ost oft en associat ed with th e u se of modalities. It h as been estimated that 8 of 10 people will suffer fr om LBP at som e tim e in th eir liv es at a lost of billion s of dollar s annually (Coste et al, 1991; Gr av es et al, 1990). Although the

etiology of LBP is div er se, m any cau ses hav e been r elat ed t o w eakness or injury of the soft tis sue in the lumbar ar ea (Begm ark , 1989; O' Sulliv an , 2000;

O' Sulliv an et al, 1997; P angabi, 1992;

Richar dson and Jull, 1995). Mu scles play an import ant r ole in the etiology , pr esent ation and tr eatm ent of low back disor der . It is know n clinically that ex cessiv e m otion beyond th e norm al phy siologic limit s, also som etim es r eferr ed t o as spinal in st ability , m ay r esult in chr onic low back pain (Hodges an d Richar dson , 1996). P anj abi (1992) defin ed

E ffe c t o f Lu m b ar S t ab iliz at io n E x e rc i s e o n S pin al In s t ab ility in P at ie n t s W ith L o w B ac k P ain :

A L it e rature Re v ie w

J eon g Y eon - t ae, B .H .S c ., R .P .T .

D ept . of Ph y sical T h er apy , S ch ool of H ealth S cien ces , T our o Colleg e

국 문 요 약

요 추 부 안 정 성 운 동 이 요 통 환 자 의 척 추 불 안 정 성 에 미 치 는 영 향 : 문 헌 고 찰

정 연 태

토우로대학 보건과학대학원 물리치료학과

요통은 산업화된 현대사회에서 흔히 발생하는 질환이다. 요통의 다양한 원인 중에서 도 척추의 정상 가동범위를 넘은 불안정성이 요통의 한 원인으로 보고되고 있다. 이 문 헌고찰의 목적은 요추 부위의 안정성을 부여하는 운동 프로그램 후 근육 기능의 강화, 통증의 감소를 보고한 논문들을 비교, 분석하는 것이다. 그리하여 요통의 한 원인인 척 추의 안정성을 증가시켜 요추 부위의 통증을 감소시키고 기능을 향상시키는 운동 프로 그램의 효과를 입증하는 것이다.

핵 심 단 어 : 척추 불안정성; 요추 안정성.

spinal in st ability in t erm s of a r egion of laxity ar ound the neutr al r esting position of a spin al segm ent called the n eutr al zone.

T he n eutr al zon e is shown to be lar g er with int er segm ent al injury and interv er - t ebr al disc degen er ation and sm aller with simulat ed mu scle for ces acr oss a m otion segm ent . Begmark (1989) hypothesized th e pr esence of t w o mu scle sy stem s that act in the m aint en ance of spinal st ability . T he global mu scle sy st em con sist s of lar g e t or que pr odu cing mu scles that act on the trunk an d spine without dir ectly att achin g t o it . T hese mu scles include r ectu s abdom - inis, oblique abdominis ex t ernu s, and the thor acic part of lumbar iliocost alis. T hese mu scles pr ovide gen er al trunk st abilization but ar e not capable of having a dir ect segm ent al influen ce on the spine. T he local mu scle sy st em con sist s of mu scles that dir ectly att ach t o the lumbar v ert ebr ae, and they ar e r espon sible for pr oviding seg - m ent al st ability an d dir ectly contr olling the lumbar segm ent s. Lumbar multifidu s, psoas m ajor , quadr atu s lumborum , the lumbar part s of the lumbar iliocost alis an d lon gi- ssimu s, and tr an sv er su s abdominis form part of this local mu scle sy st em .

In a r ecent study by Hides an d his associat es (1996) it w as con cluded that r etr aining of the deep mu scle cocontr action could r ev er se the inhibition of th e lumbar multifidu s demon str at ed by patient s with a fir st episode of acut e low back pain . In addition , ther e is incr ea sing evidence that lumbar multifidu s an d tr an sv er su s abdom - inis ar e pr efer entially affected in the pr esence of low back pain and lumbar st ability (Hides et al, 1996; Hides et al, 1994). Specific subm axim al tr aining of these st ability mu scles of th e lumbar spin e

decr ea sed both pain an d functional dis - ability in those suffering fr om m echanical LBP (Richar dson an d Jull, 1995). Clinically , this appr oach appear s particularly effectiv e when the segm ent al st ability of the lumbar spine has been compr omised.

F urther un der st an ding of the effect s of spinal st abilization ex er cise and m ot or con - tr ol ar e neces sary for the effectiv e tr eat - m ent of LBP . T he purpose of this study w as t o determin e the effect

M e t h o d s

T w o articles w er e r eview ed for the con cerning t opic. T hese tw o articles w er e found t o be th e m ost pertinent t o be r eview ed becau se they pr ov ed the effect of spinal st abilization ex er cise in patient s with low back pain .

T he fir st article (O' Sulliv an et al, 1997) looked at the effect of specific st abilizing ex er cise

in the tr eatment of chr onic low back pain . T he second article (Hides et al, 1996) inv estig at ed the effectiv enes s of specific and localized ex er cise ther apy .

S ubje c t s an d D at a Colle c ti on

F orty - four patient s w er e as signed r an -

domly t o t w o tr eatm ent gr oups. A ccor ding

t o in clu sion crit eria, the sample con sisted

of 44 patient s of either gen der bet w een th e

ages of 16 and 49 wh ose LBP sympt om s

(w ith or without pain ext en sion int o the

low er limb s) w er e r ecurr ent an d had per sist ed lon ger th an 3 m onth s with n o sign of abating . P atient s w er e ex clu ded fr om entry to the trial if they had: a clinical pr esent ation con sider ed not attrib - ut able t o the pr esen ce of the spondyloly sis or spondylolisth esis by the tr eating medical specialist ; a diagnosed psy chological illness ; difficulty under st anding English , pr eclu ding them fr om an sw erin g the questionn air es ; pr eviou s spinal sur gery ; or an inflam - m at ory j oint disease or display ed ov ert neur ological sign s (sen sory or m ot or par al- y sis). P atient s w er e r ecruit ed fr om gen er al and specialist m edical pr actices, pain m anagem ent clinics, an d phy sical ther apy pr actices.

Pr oper pr ocedur es for inform ed con sent w er e follow ed. P atient s w er e selected on the basis of their symptom s and clinical pr esent ation being con sider ed attribut able t o the r adiologic diagn osis of spondyloly sis or spondylolisthesis by their tr eating m edi- cal specialist .

A number of fact or s w er e combined t o limit the gener alizability of this stu dy . F ir st , sm all sample size limit ed the gene- r alizability of r esult s becau se: sm all gr oups t ended t o be les s r epr esent ativ e of t ar get population s ; r an dom assignment t o condi- tion s can be less successful; and th e st a - tistical pow er of th e an alytical pr ocedur es w as limit ed. Anoth er limit ation of this study w as the lack of ex er cise supervision , which decr eased int ernal v alidity . S econ d, this study m easur ed pain an d functional disability u sing the sh ort form of question - nair e. T his m easur em ent w as quit e subjec- tiv e. Specific ex er cise gr oup under w ent a 10 w eek tr eatm ent pr ogr am dir ect ed by one of four differ ent phy sical ther apist s. T his

study did not hav e writt en st andar dized guidelin es for ex er cises, which may lead the lack of int ern al v alidity .

Author s believ ed that McGill pain qu estionn air e w as sufficiently sen sitiv e t o dem on str at e differ en ces at st atistical lev els . Also, Osw estry disability questionn air e w as u sed to giv e a per cent age scor e th at indicat ed each patient ' s lev el of functional disability . T his qu estionn air e w as th ought t o be sufficiently sen sitiv e t o m onit or these chan ges.

T his study u sed a Cybex Electr onic Digital Inclin om et er t o ev aluat e lumbar spine an d hip sagittal r an ge of m otion in st anding . T he r epeat ability of the inclin om - et er for m easuring lumbar curv atur e in the population with chr onic low back pain has been established and v alidated ag ain st lumbar spine r adiogr aph s .

Surface electr omy ogr aphy w as also u sed t o r eport abdominal mu scle r ecruitm ent patt ern s. T his m aneuv er ha s been found in the lit er atur e.

Author s m entioned that this m aneuv er has been foun d in the h ealthy mu scles t o activ at e the deep abdominal mu scles with minim al activity of th e r ectu s abdominis .

A r an domized, contr olled clinical trial, t est - r et est design with t w o tr eatment gr oup s and a blind inv estigation w er e u sed.

Aft er completion of the initial t estin g , th e

patient s w er e r an domly assign ed t o either

the specific ex er cise gr oup (SEG) or a

contr ol gr oup (CG). During th e followin g

four m onth period, they w er e allocat ed to

either gr oup . T he int erv ention period w as

10 w eek s. At th e completion of th e

int erv ention period, patient s w er e again

t est ed by the same inv estigator blinded t o

gr oup allocation . Subject s w er e then

r eassessed by post al qu estionn air e for a 3, 6, and 30 m onth follow - up. T he SEG under w ent a 10 w eek tr eatment pr ogr am on a w eekly basis by one of four m anipulativ e phy sical th er apist s. T he ex er cises w er e design ed t o: 1) tr ain the specific contr ac- tion of the deep abdominal mu scles without sub stitution fr om lar ge tor qu e pr oducin g mu scles such as r ectu s abdominis and ext ernal oblique u sing the abdomin al dr aw - in g in m aneuv er ; and 2) tr ain specific contr action of deep abdomin al mu scles with 10 activ ation of lumbar multifidu s pr oxim al t o the par s defect .

T he ex er cise pr ogr am str essed that these ex er cises w er e pr ecise isom etric contr ac- tion s an d w er e designed to take appr ox i- m at ely 10～15 minut es with a daily basis.

T he h old tim e for these ex er cises w as incr eased gr adually th e point wh en patient s w er e able to perform 10 contr action s with 10 second holds.

Experiment al gr oup perform ed an iso- m etric spinal st abilization ex er cise pr ogr am t wice a w eek for 15 minut es. Subject s w as asked to complet e ex er cise sheet t o m oni- t or th eir compliance.

Ex er cise pr ogr am s w er e as follow s : 1. In four point kneeling , subject s dr aw abdominal w all up an d in and hold this position for 10 secon ds. T he rib cage an d pelvis should r em ain still, and th e subject s mu st continue t o br eathe norm ally thr ough - out the abdomin al dr aw ing in and holding contr action .

2. In pr on e, subject s dr aw low er abdominal w all up an d in while m ain - t aining neutr al lor dosis. T h e rib cage an d pelvis should r em ain still, and the subject mu st continu e t o br eathe normally .

3. In sitting and upright st an din g , sub - ject dr aw abdomin al w all up an d in t o facilit at e the contr action of the pelvic floor and low er and middle fiber s of tr an sv er su s abdominis with gentle contr olled later al cost al diaphr agm br eathing without global mu scle sub stitution .

S t ati s tic al D e s ig n

1. Repeated m easur es analy sis of v ar - iance w as u sed: 1) t o a ssess for gr oup differ ences at entry t o the trial on the baseline data ; 2) t o asses s change within each gr oup aft er the int erv ention period; 3) t o assess differ en ces bet w een th e t w o gr oup s aft er the int erv ention period on the chan ge scor es (th e differ en ce betw een th e follow - up scor e an d the ba seline scor e for each individual) of each m easur e.

2. T w o- w ay r epeated m easur es an aly sis of v ariance w as carried out on the ques - tionn air e dat a t o assess differ ences within and bet w een the gr oups aft er th e int er - v ention an d at th e 3, 6, and 30 m onth follow - up. T he lev el for st atistical signifi- cance w a s set at the 95% confiden ce limit .

S ubje c t s an d D at a Colle c ti on

Men and w om en w er e r ecruit ed for the

study in the fir st in st ance if they w er e: 1)

aged 18- 45 y ear s ; 2) ex periencin g th eir

fir st episode of unilat er al and mechanical

LBP bet w een T

and the glut eal fold

(w ith or without pain r adiation int o the

low er limb ); and 3) showin g r estricted

r ange of lumbar motion . Ex clu sion crit eria

w er e pr eviou s hist ory of LBP or injury ,

pr eviou s lumbar sur gery , spin al abnor -

m alities indicat ed on r adiogr aph s, neur o-

mu scular or joint disease, r eflex and/ or

m ot or sign s of nerv e r oot compr ession or cauda equin a compr ession , evidence of sy st emic disease, car cinom a or or gan dis - ease, pr egnan cy , an d any sport s or fitness tr aining inv olving th e low back mu scles done in th e pa st 3 m onth s.

F orty - one patient s w er e accept ed pr ovisionally int o the study . Random as - signm ent t o the contr ol (gr oup 1, m edical m anagem ent ) or th e tr eatm ent gr oup (gr oup 2, m edical m an agem ent and specific ex er cise ther apy ) w as achiev ed by selec- ting the gr oup number (one or t w o) fr om sealed an d shuffled env elopes. T w enty patient s w er e allocated r andomly into gr oup 1, and 21 patient s w er e allocat ed int o gr oup 2. T her e w er e 10 m en and 10 w om - en in gr oup 1, an d 8 m en an d 13 w omen in gr oup 2. T h e m ean ag e of patient s in gr oup 1 w as 31.0±7.9 y ear s (r ange, 17～45 year s), an d th e m ean age for patient s in gr oup 2 w as 30.9±6.5 y ear s (r ange, 22～44 year s).

T he article stated that inform ed con sent w as obt ain ed fr om the subject s . T he study w as appr ov ed by the Medical Ethical Re- view committ ees of th e Univ er sity of Queen slan d and the Mat er A dult Hospit al, Brisbane, Au str alia.

Key term s th at the author s identified w er e: 1) r an ge of motion (ROM ) r eferrin g t o full motion possible; 2) str aight leg r aise (SLR) r eferring to hip flexion without bent knee.

T his study ' s limitation s w er e that it w a s not a pur ely r an dom sampling fr om an all inclu siv e population . Inclu sion crit eria w as t oo strict so that this study lost couple of subject s

A ssumption s of the study w as that localized phy sical tr aining , which can r e-

st or e mu scle size at the segm ent al lev el, m ay be a necessary at th e fir st st age of r ehabilit ation befor e m or e gen er alized st a - bilization tr aining , ther efor e, mu scle contr ol at the segm ent al lev el might be better assur ed. It w as assum ed that asymmetry bet w een each side of the lumbar spine has t o be gr eater than 11% for patient s t o be con sider ed for study . Author s also believ ed that multifidu s mu scle dy sfunction in patient s with acut e LBP also could be r elat ed to out com e and r ecurr en ce of LBP symptom s.

T he following equipment w as utilized : 1) lumbar m otion w as m easur ed u sin g a t w o- inclinom eter m ethod for lumbar flexion ; and 2) ext en sion an d a single- inclinom eter m eth od w a s u sed for lumbar lat er al flex ion . Oil- filled Rippstein goniom et er s w er e u sed for all m easur em ent s of lumbar m otion . SLR also m easur ed u sing the oil- filled go- niom et er . Measur ement of multifidu s cr oss section al ar ea w as m easur ed u sing r eal - tim e ultr asound imaging . All ultr asound im aging w as perform ed by the blinded ultr ason ogr aph er u sing r eal- tim e ultr asoun d appar atu s (T oshiba S onolayer V SSA - 100A , T oshiba Medical Sy st em s, Japan ) equipped w ith a 5 ㎒ conv ex arr ay tr an sducer .

All subj ect s w er e asses sed initially t o pr ovide baselin e data and then r easses sed w eekly for 4 w eek s. P atient s who did not att ain full pain - fr ee function w er e r em ov ed fr om the study at 4 w eek s. T h e r em aining patient s w er e r ea ssessed durin g the 10th w eek of the study . Habitual activity lev els and mu scle cr os s section al ar ea w er e det ermined at 10th w eek s.

Medical m anag ement of the low back

pain for the contr ol gr oup included advice

on bed r est and minor an algesics. Experi- m ent al gr oup r eceiv ed m edical m an agem ent and th er apeutic ex er cises which w er e designed t o r e- educat e the multifidu s mu s - cle. T h ey inv olv ed facilit ating in activ e and isom etric multifidu s contr action in co - contr action with the deep abdomin al mu s - cles.

Compar ability of baselin e m easur em ent s bet w een the gr oups w as as sessed u sing one- w ay analy sis of v ariance (ANOVA ) t o ex amine differ en ces in all baselin e m ea - sur em ent s. Analy sis of v ariance also w as u sed t o ex amine differ ences bet w een gr oup s ov er tim e for all out com e m easur es u sed. If patient s did not hav e localized and segm ent al mu scle asymm etry at the tim e of this fir st a ssessm ent , their data w er e not included in further analy sis. Analy sis of v ariance also w a s u sed t o ex amine the dat a fr om the other v ert ebr al lev els m ea - sur ed during the fir st w eek . Corr elation analy sis w a s u sed to t est for r elation ships am ong mu scle r ecov ery , pain , disability , and r ange of motion .

R e s u lt s

F or the purpose of the r esult s section , the r esear ch studies m ainly focu s on the efficacy of specific st abilizin g ex er cise. T h e studies that focu sed on efficacy of specific st abilizin g ex er cise unanim ou sly agr eed that it decr eases pain and incr ea sed func- tional disability lev el (Hides et al, 1996;

Hides et al, 1994; O ' Sulliv an . 2000).

Analy sis of differ en ces within each gr oup aft er the int erv ention period r ev ealed significant differ en ces in the specific ex er - cise gr oup aft er the int erv ention period

(p < .05) with a decr ease in pain int en sity (F =75.5, df =1.20, p< .0001), pain descript or scor es (F =35.8, df =1.20, p < .0001), and a r eduction in fun ctional disability lev el (F =49.1, df =1.20, p< .0001).

Analy sis of th e follow - up dat a r ev ealed significant differ ences bet w een the specific ex er cise gr oup and contr ol gr oup on th e basis of pain int en sity (F =14.4, df =1.32, p =.0006).

Analy sis of gr oup differ en ces on the basis of the pain descript or scor es r ev ealed significant differ ences bet w een the specific ex er cise gr oup an d contr ol gr oup (F =6.1, df =1.32, p =.0187).

Hides and his associat es (1996) inv es - tigat ed the effectiv eness of specific an d localized ex er cise th er apy on mu scle r ecov - ery . P atient s in gr oup 1 r eceiv ed m edical tr eatment only . P atient s in gr oup 2 r eceiv ed m edical tr eatm ent an d specific and localized ex er cise th er apy . P atient s w er e r eassessed at a 10 w eek follow - up ex ami- nation . Hides an d his a ssociates u sed ultr asoun d im aging t o mea sur e multifidu s cr oss - sectional ar ea . T his stu dy r ev ealed that multifidu s mu scle r ecov ery w as n ot spont aneou s on r emission of painful symp - t om s in patient s in gr oup 1. Mu scle r ecov - ery w as m or e r apid and m or e complet e in patient s in gr oup 2 who r eceiv ed ex er cise ther apy .

Analy sis of v ariance r ev ealed th at tot al mu scle r ecov ery (F =103.5, df =1.14, p =.0001) and w eekly mu scle r ecov ery (F =34.75, df =4.14, p =.0001) differ ed significantly bet w een gr oup s.

D i s c u s s i o n a n d Co n c lu s i o n s

T her e has been gr ow ing int er est in how the neur omu scular sy st em support s an d contr ols the spin al segm ent . Support is gr owin g for the functional differ entiation bet w een global and local mu scles in r elation t o spinal contr ol. Mor e pertinently , link s ar e n ow emer ging betw een low back pain an d m ot or contr ol deficit s in mu scles of the local sy st em , not ably th e tr an sv er ses abdominis an d lumbar multifidu s (Hides et al, 1996; Hides et al, 1994; Hodg es and Richar dson , 1996). Lumbar multifidu s has been sh own to r eact by inhibition at a segm ent al lev el in acute episodes of low back pain (Hides et al, 1996; Hides et al, 1994). O ' Sulliv an and his as sociat es (1992) dem on str at ed that specific ex er cise tr aining of the st ability mu scles of the trunk is effectiv e in r educin g pain an d fun ctional disability in patient s with chr onically symptom atic spondyloly sis and spondy - lolisthesis. Crisco an d P anj abi (1991) r eport ed that lumbar st ability is m aint ained in viv o by incr easing the activity (stiff- ness) of the lumbar segm ent al mu scles . T hey also emphasized that the import ance of m otor contr ol to coor dinat e mu scle r ecruitm ent bet w een lar ge trunk mu scles and sm all intrin sic mu scles during func- tional activities t o en sur e st ability is m ain - t ained. T he concept of differ ent trunk mu scles playin g differ ent r oles in the pr ovision of dynamic stability t o the spine w as pr oposed by Begmark (1989). He hypothesized the pr esen ce of t w o mu scle sy st em s in the m aint enance of spinal st ability . T he global mu scle sy st em con - sist s of lar ge and t or que pr oducing mu scles that act on th e trunk and spin e without being dir ectly attached to it . T hese mu scles inclu de the r ectu s abdominis,

ext ernal oblique, an d the thor acic part of lumbar iliocost alis.

T hey pr ovide gener al trunk st abilization , but they ar e not capable of having dir ect segm ent al influen ce on the spine. T he local mu scle sy st em con sist s of mu scles that dir ectly attach t o the lumbar v ert ebr ae an d ar e r espon sible for pr oviding segment al st ability and dir ectly contr ollin g the lumbar segm ent s. By definition , the lumbar multi- fidu s, tr an sv er se abdominis, and post erior fiber s of the int ernal oblique form part of this local mu scle sy st em . T her efor e, if the basic m orphology of the lumbar spin e is compr omised as in the case with symp - t om atic spondyloly sis an d spon dylolisthesis, the n eur omu scular sy st em m ay be tr ained t o compen sate and t o pr ovide dynamic st ability t o the spin e during the dem ands of daily livin g .

T he co- contr action of the deep

abdominal mu scles with the lumbar multi-

fidu s h as the pot ential t o pr ovide a dy -

namic cor set for the lumbar spine en -

hancing it s segm ental st ability during

function al ta sk s and th e m aint enance of

neutr al spin al postur es. O' Sulliv an an d his

associat es (1997) an d Hides (1996) show ed

disagr eem ent in pain scor e. P anjabi (1992)

st at ed that ther e w as significant differ ence

bet w een the specific ex er cise gr oup and

contr ol gr oup on th e basis of function al

disability lev el. How ev er , Hides (1996)

con cluded that disability analy sis ov er time

w as n ot significantly differ ent bet w een

gr oup s. Both studies only compar ed the

effect of medical tr eatm ent and specific

ex er cise gr oups. Both studies had only t w o

tr eatment gr oup. Contr ol gr oup r eceiv ed

m edical tr eatm ent , an d experim ental gr oup

r eceiv ed specific st abilizing ex er cise. Both

studies did not hav e true contr ol gr oup (n o m edical tr eatm ent gr oup). S o, it is har d to see the tru e effect of spin al stabilization ex er cise. Study limit ation s included a biased selection pr ocess becau se of t oo strict in clu sion criteria .

Specific ex er cises dir ect ed at the local mu scle sy stem hav e been adv ocat ed by phy sical ther apist s as an effectiv e m ean s of tr eatin g chr onic low back pain con di- tion s by enh ancin g the dynamic st ability of the lumbar spine (Richar dson and Jully , 1995). Recently , Hides an d his associat es (1996) carried out a r andomized contr olled trial in a gr oup of subj ect s aft er their segm ent al loss of lumbar multifidu s at the symptom atic lev el w as det ect ed by ultr a - son ogr aphy . Interv ention gr oup patient s w er e tr eat ed with specific ex er cises similar t o that carried out in O ' Sulliv an s stu dy , while contr ol gr oup subject s r eceiv ed m edical tr eatm ent .

At follow - up aft er one y ear , patient s in the ex er cise gr oup r eport ed a significant r eduction in pain r ecurr en ce wh en com - par ed with contr ol subject s. T he specific ex er cise appr oach u sed in O' Sulliv an and Hides studies w as v ery differ ent fr om gener al ex er cise appr oaches comm only ad- v ocat ed in the r ehabilit ation of patient s with chr onic low back pain . T his appr oach w as aimed t o specifically tr ain the iso- m etric co- contr action of the deep ab - domin al mu scles and lumbar mutlifidu s with minim al co- activ ation of global sy st em mu scles. On ce this patt ern of co - contr action w as achiev ed, it w as imm e- diat ely incorpor ated into st atic postur es (such as sitting , st anding , an d su stained flex ion ), function al activities (such as bending , t wisting , an d liftin g ), and aer obic

activities (such as w alking , swimming , or running ).

A challenge for furth er r esear ch will be t o further inv estigate the pot entials of this form of ex er cise int erv ention to alt er aut o- m atic patt ern s of mu scle r ecruitm ent within the trunk mu sculatur e in low back pain population . Mor e r esear ch is needed t o under st and the natur e of these m ot or - contr ol pr oblem s in the deep mu scles in patient s with low back pain an d partic- ularly their implication s for per sistent an d r ecurr ent low back pain . F urther clinical studies need t o be undertaken t o t est the effectiv en ess of the specific st abilization pr ogr am .

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