Research Review By Dr. Brynne Stainsby©

Audio:

Download MP3

Date Posted:

January 2020

Study Title:

Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis

Authors:

Owen PJ, Miller CT, Mundell NL et al.

Author's Affiliations:

Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Victoria, Australia; Department of Orthopaedics, Institute of Clinical Sciences, University of Gothenburg, Sweden; Faculty of Health, Biostatistics Unit, Deakin University, Victoria, Australia.

Publication Information:

British Journal of Sports Medicine 2019; doi:10.1136/bjsports-2019-100886

Background Information:

Low back pain (LBP) – defined as pain below the costal margin and above the gluteal fold, with or without leg pain – is the leading cause of disability and the most common non-communicable disease (1-3). Although chronic LBP (lasting 12 weeks or longer) comprises approximately 20% of cases of LBP, it accounts for approximately 80% of the direct costs for treating LBP (4, 5). Although a specific cause can rarely be identified (leading to the common diagnosis of non-specific or mechanical LBP), it is important to understand the efficacy of interventions that may be useful in treating chronic LBP (cLBP). Exercise has consistently been found to be more effective than non-exercise-based treatments in adults (6-8); however, little research has been done to determine if specific types of exercise are more effective for the treatment of non-specific cLBP.

In a network meta-analysis (NMA), researchers are able to incorporate data from RCTs that do not necessarily have the same comparator group in a network of studies (9), allowing the authors to include studies that tested two or more kinds of treatment, with or without a control (10). In other words, this allows multiple treatments (that is, three or more) to be compared using both direct comparisons of interventions within randomized controlled trials and indirect comparisons across trials based on a common comparator. This allows for direct comparison of treatment and indirect comparisons with the network (9, 10) and also allows researchers to rank interventions as comparably more or less effective.

The aim of this study was to conduct a systematic review and NMA on the effectiveness of specific exercises in adults with non-specific, chronic LBP. Additionally, the authors examined treatment effects on subjective physical function, mental health, analgesic use and objective trunk muscle strength and endurance. Finally, this reviewed aimed to compare exercise training with “hands-on” treatment (i.e. manual therapy) and “hands-off” treatment (i.e. education).

Pertinent Results:

Literature Search Results and Study Characteristics:
  • The initial search yielded a total of 9437 records, with an additional 106 after reference list search.
  • 808 records were eligible for full-text review, 89 were included in qualitative analysis (11-99), 55 were eligible for pair-wise meta-analyses and 82 were eligible for NMA.
  • The included studies typically demonstrated random sequence generation and low risk of selective outcome reporting and other biases, but allocation concealment and blinding of patients and personnel was not typically well done.
  • The included studies (patients: n = 5578) included 131 exercise training interventions (patients: n = 3924) and 59 non-exercise comparators (patients: n = 1654).
  • Exercise training interventions included: aerobic (studies: n = 5, patients: n = 127); other (studies: n = 12, patients: n = 290); McKenzie (studies: n = 7, patients: n = 114); multimodal (studies: n = 23, patients: n = 756); Pilates (studies: n = 13, patients: n = 350); resistance (studies: n = 12, patients: n = 472); stabilization/motor control (studies: n = 39, patients: n = 1062); stretching (studies: n = 8, patients: n = 222); water-based (studies: n = 6, patients: n = 144) and yoga (studies: n = 6, patients: n = 387).
  • The exercise frequency ranged from one to seven days per week, while therapist hands-on controls were performed on 0.3-5 days per week.
Network Meta-Analysis Results:

Pain:
  • Seventy studies assessed pain and were eligible for NMA. Exercise training was found to be more effective than hands-off or hands-on controls.
  • When compared to true control, Pilates (p < 0.001), aerobic (p = 0.006), stabilization/motor control (p < 0.001), multimodal (p < 0.001), resistance (p = 0.002) and “other” (p < 0.001) exercise training modes all result in lower pain.
  • The model indicates that Pilates (in particular), aerobic and stabilization/motor control were the best interventions for pain, but the quality of evidence for the ranking was low.
  • The pooled standard mean deviation (considered as an effect size) for Pilates, stabilization/motor control and aerobic training was found to be large (> 0.8).
  • It is also important to note that these interventions resulted in clinically significant changes on the visual analog scale for pain intensity, meaning these interventions have the potential to decrease pain intensity by a clinically meaningful amount.
Physical Function:
  • Sixty-three studies assessed physical function and were eligible for NMA. Exercise training was found to be more effective than hands-off or hands-on controls for physical function.
  • When compared to true control, stabilization/motor control (p < 0.001), resistance (p < 0.001), water-based (p = 0.004), Pilates (p = 0.001), yoga (p = 0.015), multimodal (p = 0.002), aerobic (p = 0.029), and “other” (p = 0.017) exercise training all result in improved physical function.
  • The model indicates that stabilization/motor control, resistance, water-based, Pilates and yoga were the best interventions for physical function, but the quality of evidence for the ranking was low.
Mental Health:
  • Twenty-four studies assessed mental health, and 16 were eligible for NMA. Exercise training was found to be more effective than hands-off or hands-on controls for mental health.
  • When compared to true control, resistance (p = 0.003), aerobic (p = 0.024) and stabilization/motor control (p = 0.031) exercise training all resulted in improved mental health.
  • The model indicates that resistance and aerobic training have the highest probability of being the best interventions for mental health, but the quality of evidence for the ranking was low.
Strength & Endurance:
  • Eight studies assessed trunk muscle strength, and four were eligible for NMA. Exercise training was found to be more effective than hands-off or hands-on controls for trunk muscle strength.
  • Eight studies assessed trunk muscle endurance, but NMA was not possible. Exercise training was found to be more effective than hands-off or hands-on controls for trunk muscle endurance.

Clinical Application & Conclusions:

This network meta-analysis (NMA) found that Pilates (for pain), resistance and stabilization/motor control (for physical function) and resistance and aerobic training (for mental health) were the most effective exercise interventions in adults with chronic, non-specific low back pain (cLBP). It is helpful for clinicians to note that true control was the least effective intervention for all outcomes, followed by hands-off treatment (for pain and physical function) and hands-on treatment (for mental health). This review highlights the importance of understanding a patient’s goals and expectations and implementing these into an evidence-based treatment plan.

While it is unlikely that one type of exercise will be the single best approach to treating all patients with cLBP, this review and NMA provides important evidence that active therapies, particularly Pilates, resistance, stabilization/motor control and aerobic exercise training, are effective therapies. The authors suggest that treatment should be guided, progressive and individualized to the patient presentation, goals and exercise preferences.

Study Methods:

  • The literature search was developed, piloted and refined based on the method guidelines for systematic reviews in the Cochrane Back and Neck Group (22) and previously published systematic reviews (11-13).
  • Five databases were searched from inception to May 2019 using appropriate search terms, relevant combinations and limiters for each database. Reference lists of relevant systematic reviews were screened for additional resources.
  • One author screened the list to exclude duplicates. Two authors independently screened titles and abstracts for inclusion. Full texts of articles meeting inclusion criteria were then independently screened. Disagreement was adjudicated by a third reviewer.
  • Randomized controlled/clinical trials with an exercise training intervention and a total sample size of ≥ 20 patients, published in peer-reviewed journals (in any language) which targeted adults (≥ 18) with non-specific, chronic (≥ 12 weeks) low back pain (localized between the costal margin and inferior gluteal folds, with or without leg pain) (3,4) were included. Interventions included the prescription of exercise alone, for at least four weeks of duration and non-exercise comparator groups included true control, therapist “hands-on” control and therapist “hands-off” control. Studies were required to include at least one outcome measure related to pain intensity, function, trunk muscle strength or endurance, analgesic use or mental health.
  • Two authors then independently appraised each study using the Cochrane Collaboration Risk of Bias Tool (53) to evaluate the potential for selection, performance, detection, attrition, reporting and other biases. For each potential source of bias, studies were classified as having a low, high or unclear risk. Note: Given the studies included exercise interventions, it was not possible to blind those patients regarding treatment allocation, and patient blinding was deemed as high for all studies and not included in the overall risk of bias assessment for each study..
  • The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of the evidence when ranking the treatments from the NMA (54).
  • Two reviewers independently extracted relevant data from high-quality studies. When it was not possible to extract the required data, this information was requested from the authors a minimum of three times over a four-week period.
  • In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Network Meta-Analyses (PRISMA-NMA) guidelines (18), NMA was performed using a five-step approach for statistical analysis and comparative effectiveness ranking. The GRADE approach was used to evaluate the quality of the evidence from the NMA (54).

Study Strengths / Weaknesses:

Strengths:
  • A thorough and systematic search not limited by publication date or language, or the type of intervention or comparators was conducted.
  • The authors independently screened titles, abstracts and full texts.
  • Assessment of risk of bias was performed with a validated set of criteria.
  • In addition to methodological quality, clinical relevance was also assessed.
  • Two authors independently extracted the data from the included articles, and reviewers followed up with authors to access required information.
  • Performing a NMA allowed the reviewers to directly compare and rank interventions as comparably more or less effective.
Weaknesses:
  • The primary limitation of this study relates more to the quality of the body of evidence than the methodology of the review itself.
  • Although the authors used a validated tool to assess risk of bias, the overall low quality of evidence in all included studies mean the findings must be interpreted with caution. The authors did address this limitation by applying the GRADE approach.
  • Many of the included studies did not report on safety or adverse events; however, there is low quality evidence that exercise does not cause serious harm and adverse events are typically limited to transient muscle soreness and pain.

Additional References:

  1. Hoy D, March L, Brooks P, et al. The global burden of low back pain: estimates from the global burden of disease 2010 study. Ann Rheum Dis 2014; 73: 968–74.
  2. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the global burden of disease study 2010. The Lancet 2012; 380: 2163–96.
  3. van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 2006; 1: S169–91.
  4. Hoy D, Brooks P, Blyth F, et al. The epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010; 24: 769–81.
  5. Hashemi L, Webster BS, Clancy EA, et al. Length of disability and cost of work-related musculoskeletal disorders of the upper extremity. J Occup Environ Med 1998; 40: 261–9.
  6. Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med 2005; 142: 776–85.
  7. Searle A, Spink M, Ho A, et al. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clin Rehabil 2015; 29: 1155–67.
  8. van Middelkoop M, Rubinstein SM, Verhagen AP, et al. Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol 2010; 24: 193–204.
  9. Shim S, Yoon B-H, Shin I-S, et al. Network meta-analysis: application and practice using Stata. Epidemiol Health 2017; 39: e2017047.
  10. Mills EJ, Thorlund K, Ioannidis JPA. Demystifying trial networks and network meta-analysis. BMJ 2013; 346: f2914.
  11. Mostagi FQRC, Dias JM, Pereira LM, et al. Pilates versus general exercise effectiveness on pain and functionality in non-specific chronic low back pain subjects. J Bodyw Mov Ther 2015; 19: 636–45.
  12. Shirado O, Doi T, Akai M, et al. Multicenter randomized controlled trial to evaluate the effect of home-based exercise on patients with chronic low back pain: the Japan low back pain exercise therapy study. Spine 2010; 35: E811–9.
  13. Ferreira ML, Ferreira PH, Latimer J, et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: a randomized trial. Pain 2007; 131: 31–7.
  14. Kliziene I, Sipaviciene S, Vilkiene J, et al. Effects of a 16-week Pilates exercises training program for isometric trunk extension and flexion strength. J Bodyw Mov Ther 2017; 21: 124–32.
  15. Kofotolis N, Kellis E. Effects of two 4-week proprioceptive neuromuscular facilitation programs on muscle endurance, flexibility, and functional performance in women with chronic low back pain. Phys Ther 2006; 86: 1001–12.
  16. Patti A, Bianco A, Paoli A, et al. Pain perception and Stabilometric parameters in people with chronic low back pain after a Pilates exercise program. Medicine 2016; 95: e2414.
  17. Shahrjerdi S, Golpayegani M, Daghaghzadeh A, et al. The effect of Pilates-based exercises on pain, functioning and lumbar lordosis in women with non-specific chronic low back pain and hyperlordosis. J Zanjan Univ Med Sci Health Serv 2014; 22: 120–31.
  18. Soares P, Cabral V, Mendes M, et al. Effects of school-based exercise program of posture and global postural reeducation on the range of motion and pain levels in patients with chronic low back pain. Rev Andaluza Med Dep 2016; 9: 23–8.
  19. Machado LAC, Azevedo DC, Capanema MB, et al. Client-centered therapy vs exercise therapy for chronic low back pain: a pilot randomized controlled trial in Brazil. Pain Med 2007; 8: 251–8.
  20. Brooks C, Kennedy S, Marshall PWM. Specific trunk and general exercise elicit similar changes in anticipatory postural adjustments in patients with chronic low back pain. Spine 2012; 37: E1543–50.
  21. Cruz-Diaz D, Romeu M, Velasco-Gonzalez C, et al. The effectiveness of 12 weeks of Pilates intervention on disability, pain and kinesiophobia in patients with chronic low back pain: a randomized controlled trial. Clin Rehabil 2018; 32: 1249–57.
  22. Groessl EJ, Liu L, Chang DG, et al. Yoga for military veterans with chronic low back pain: a randomized clinical trial. Am J Prev Med 2017; 53: 599–608.
  23. Keane LG. Comparing AquaStretch with supervised land based stretching for chronic lower back pain. J Bodyw Mov Ther 2017; 21: 297–305.
  24. Young KJ, Je CW, Hwa ST. Effect of proprioceptive neuromuscular facilitation integration pattern and Swiss ball training on pain and balance in elderly patients with chronic back pain. J Phys Ther Sci 2015; 27: 3237–40.
  25. Mbada CE, Ayanniyi O, Ogunlade SO, et al. Influence of Mckenzie protocol and two modes of endurance exercises on health-related quality of life of patients with long-term mechanical low-back pain. Pan Afr Med J 2014; 17.
  26. McIlveen B, Robertson VJ. A randomised controlled study of the outcome of hydrotherapy for subjects with low back or back and leg pain. Physiotherapy 1998; 84: 17–26.
  27. Palekar T, Das A, Pagare V. A comparative study between core stabilization and superficial strengthening exercises for the treatment of low back pain in two wheeler riders. Int J Pharm Bio Sci 2015; 6: B168–76.
  28. Saggini R, Cancelli F, Bonaventura D V, et al. Efficacy of two micro-gravitational protocols to treat chronic low back pain associated with discal lesions: a randomized controlled trial 2004; 40: 311–6.
  29. Saper RB, Lemaster C, Delitto A, et al. Yoga, physical therapy, or education for chronic low back pain: a randomized noninferiority trial. Ann Intern Med 2017; 167: 85–94.
  30. Shen YC, Shen YX. Effect of eperisone hydrochloride on the paraspinal muscle blood flow in patients with chronic low back pain: a randomized controlled observation. J Clin Rehabil Tis Eng Res 2009; 13: 1293–6.
  31. Steele J, Bruce-Low S, Smith D, et al. A randomized controlled trial of limited range of motion lumbar extension exercise in chronic low back pain. Spine 2013; 38: 1245–52.
  32. Ui-Cheol J, Jae-Heon SIM, Cheol-Yong KIM, et al. The effects of gluteus muscle strengthening exercise and lumbar stabilization exercise on lumbar muscle strength and balance in chronic low back pain patients. J Phys Ther Sci 2015; 27 :3813–6.
  33. Valenza MC, Rodriguez-Torres J, Cabrera-Martos I, et al. Results of a Pilates exercise program in patients with chronic non-specific low back pain: a randomized controlled trial. Clin Rehabil 2017; 31: 753–60.
  34. Akbari A, Khorashadizadeh S, Abdi G. The effect of motor control exercise versus general exercise on lumbar local stabilizing muscles thickness: randomized controlled trial of patients with chronic low back pain. J Back Musculoskelet Rehabil 2008; 21: 105–12.
  35. Ali S, Ali S, Memon K. Effectiveness of core stabilization exercises versus McKenzie’s exercises in chronic lower back pain. Med Forum Month 2013; 24: 82–5.
  36. Arampatzis A, Schroll A, Catal. MM, et al. A random-perturbation therapy in chronic non-specific low-back pain patients: a randomised controlled trial. Eur J Appl Physiol 2017; 117: 2547–60.
  37. Areeudomwong P, Wongrat W, Neammesri N, et al. A randomized controlled trial on the long-term effects of proprioceptive neuromuscular facilitation training, on pain-related outcomes and back muscle activity, in patients with chronic low back pain. Musculoskeletal Care 2017; 15: 218–29.
  38. Bae C-R, Jin Y, Yoon B-C, et al. Effects of assisted sit-up exercise compared to core stabilization exercise on patients with non-specific low back pain: a randomized controlled trial. J Back Musculoskelet Rehabil 2018; 31: 871–80.
  39. Byoung-Hwan OH, Hong-Hyun KIM, Cheol-Yong KIM, et al. Comparison of physical function according to the lumbar movement method of stabilizing a patient with chronic low back pain. J Phys Ther Sci 2015; 27: 3655–8.
  40. Cai C, Yang Y, Kong PW. Comparison of lower limb and back exercises for runners with chronic low back pain. Med Sci Sports Exerc 2017; 49: 2374–84.
  41. Chae-Woo LEE, Kak H, In-Sil LEE. The effects of combination patterns of proprioceptive neuromuscular facilitation and ball exercise on pain and muscle activity of chronic low back pain patients. J Phys Ther Sci 2014; 26: 93–6.
  42. Chatzitheodorou D, Kabitsis C, Malliou P, et al. A pilot study of the effects of high-intensity aerobic exercise versus passive interventions on pain, disability, psychological strain, and serum cortisol concentrations in people with chronic low back pain. Phys Ther 2007; 87: 304–12.
  43. Cho H-young, Kim E-hye, Kim J. Effects of the core exercise program on pain and active range of motion in patients with chronic low back pain. J Phys Ther Sci 2014; 26: 1237–40.
  44. Costa LOP, Maher CG, Latimer J, et al. Motor control exercise for chronic low back pain: a randomized placebo-controlled trial. Phys Ther 2009; 89: 1275–86.
  45. Cruz-Diaz D, Bergamin M, Gobbo S, et al. Comparative effects of 12 weeks of equipment-based and MAT Pilates in patients with chronic low back pain on pain, function and transversus abdominis activation. A randomized controlled trial. Complement Ther Med 2017; 33: 72–7.
  46. del Pozo-Cruz B, Hernandez Mocholi MA, Adsuar JC, et al. Effects of whole body vibration therapy on main outcome measures for chronic non-specific low back pain: a single-blind randomized controlled trial. J Rehabil Med 2011; 43: 689–94.
  47. Dundar U, Solak O, Yigit I, et al. Clinical effectiveness of aquatic exercise to treat chronic low back pain: a randomized controlled trial. Spine 2009; 34: 1436–40.
  48. Franca FR, Burke TN, Caffaro RR, et al. Effects of muscular stretching and segmental stabilization on functional disability and pain in patients with chronic low back pain: a randomized, controlled trial. J Manipulative Physiol Ther 2012; 35: 279–85.
  49. Franca FR, Burke TN, Hanada ES, et al. Segmental stabilization and muscular strengthening in chronic low back pain: a comparative study. Clinics 2010; 65: 1013–7.
  50. Gak H, Chae-Woo LEE, Seong-Gil KIM, et al. The effects of trunk stability exercise and a combined exercise program on pain, flexibility, and static balance in chronic low back pain patients. J Phys Ther Sci 2015; 27: 1153–5.
  51. Gur A, Karakoc M, Cevik R, et al. Efficacy of low power laser therapy and exercise on pain and functions in chronic low back pain. Lasers Surg Med 2003; 32: 233–8.
  52. Harts C, Helmhout P, de Bie R. Staal J. A high-intensity lumbar extensor strengthening program is little better than a low-intensity program or a waiting-list group for chronic low back pain: a randomized trial. Aust J Physiother 2009; 54.
  53. Hasanpour-Dehkordi A, Dehghani A, Solati K. A comparison of the effects of Pilates and McKenzie training on pain and general health in men with chronic low back pain: a randomized trial. Indian J Palliat Care 2017; 23: 36–40.
  54. Heidari RS, Sahebozamani M, Karimi Afshar F. Comparison of the effects of 8 weeks of core stability exercise on ball and sling exercise on the quality of life and pain in the female with non-specific chronic low back pain (nslbp). J Adv Biomed Res 2018; 26: 44–56.
  55. Hosseinifar M, Akbari A, Mahdavi M, et al. Comparison of balance and stabilizing trainings on balance indices in patients suffering from nonspecific chronic low back pain. J Adv Pharm Technol Res 2018; 9: 44–50.
  56. Hosseinifar M, Akbari M, Behtash H, et al. The effects of stabilization and McKenzie exercises on transverse abdominis and multifidus muscle thickness, pain, and disability: a randomized controlled trial in nonspecific chronic low back pain. J Phys Ther Sci 2013; 25: 1541–5.
  57. Igsoo CHO, Chunbae J, Sangyong LEE, et al. Effects of lumbar stabilization exercise on functional disability and lumbar lordosis angle in patients with chronic low back pain. J Phys Ther Sci 2015; 27: 1983–5.
  58. Kankaanpaa M, Taimela S, Airaksinen O, et al. The efficacy of active rehabilitation in chronic low back pain - Effect on pain intensity, self-experienced disability, and lumbar fatigability. Spine 1999; 24: 1034–42.
  59. Kell RT, 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 2009; 23: 513–23.
  60. Kell RT, Risi AD, Barden JM. The response of persons with chronic nonspecific low back pain to three different volumes of periodized musculoskeletal rehabilitation. J Strength Cond Res 2011; 25: 1052–64.
  61. Kim B-R, Lee H-J. Effects of proprioceptive neuromuscular facilitation-based abdominal muscle strengthening training on pulmonary function, pain, and functional disability index in chronic low back pain patients. J Exerc Rehabil 2017; 13: 486–90.
  62. Kim T, Lee J, Oh S, et al. Effectiveness of simulated horseback riding for patients with chronic low back pain: a randomized controlled trial. J Sport Rehabil 2019: 1–7.
  63. KJ K, GC H, Yook YS, et al. Effects of 12-week lumbar stabilization exercise and sling exercise on lumbosacral region angle, lumbar muscle strength, and pain scale of patients with chronic low back pain. J Phys Ther Sci 2018; 30: 18–22.
  64. Kofotolis N, Kellis E, Vlachopoulos SP, et al. Effects of Pilates and trunk strengthening exercises on health-related quality of life in women with chronic low back pain. J Back Musculoskelet Rehabil 2016; 29: 649–59.
  65. Kofotolis ND, Vlachopoulos SP, Kellis E. Sequentially allocated clinical trial of rhythmic stabilization exercises and TENS in women with chronic low back pain. Clin Rehabil 2008; 22: 99–111.
  66. Lawand P, Lombardi J.nior I, Jones A, et al. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: a randomized controlled trial. Joint Bone Spine 2015; 82: 272–7.
  67. Liu J, Yeung A, Xiao T, et al. Chen-style tai chi for individuals (aged 50 years old or above) with chronic non-specific low back pain: a randomized controlled trial. Int J Environ Res Public Health 2019; 16: 517.
  68. Macedo LG, Latimer J, Maher CG, et al. Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial. Phys Ther 2012; 92: 363–77.
  69. Masharawi Y, Nadaf N. The effect of non-weight bearing group-exercising on females with non-specific chronic low back pain: a randomized single blind controlled pilot study. J Back Musculoskelet Rehabil 2013; 26: 353–9.
  70. Mazloum V, Sahebozamani M, Barati A, et al. The effects of selective Pilates versus extension-based exercises on rehabilitation of low back pain. J Bodyw Mov Ther 2018; 22: 999–1003.
  71. Muharram A, Liu WG, Wang ZY, et al. Shadowboxing for relief of chronic low back pain. Int J Athl Ther Trai 2011; 16: 29–33.
  72. Murtezani A, Hundozi H, Orovcanec N, et al. A comparison of high intensity aerobic exercise and passive modalities for the treatment of workers with chronic low back pain: a randomized, controlled trial. Eur J Phys Rehabil Med 2011; 47: 359–66.
  73. Nambi GS, Inbasekaran D, Khuman R, et al. Changes in pain intensity and health-related quality of life with Iyengar yoga in nonspecific chronic low back pain: a randomized controlled study. Int J Yoga 2014; 7: 48–53.
  74. Noormohammadpour P, Kordi M, Mansournia MA, et al. The role of a multi step core stability exercise program in the treatment of nurses with chronic low back pain: a single-blinded randomized controlled trial. Asian Spine J 2018; 12: 490–502.
  75. HW O, Lee MG, Jang JY, et al. Time-effects of horse simulator exercise on psychophysiological responses in men with chronic low back pain. Isokinet Exerc Sci 2014; 22: 153–63.
  76. Puppin M, Marques A, Silva A, et al. Stretching in nonspecific chronic low back pain: a strategy of the GDS method. Fisioter Pes 2011; 18: 116–21.
  77. Sang Wk LEE, Suhn Yeop KIM. Effects of hip exercises for chronic low-back pain patients with lumbar instability. J Phys Ther Sci 2015; 27: 345–8.
  78. Schinhan M, Neubauer B, Pieber K, et al. Climbing has a positive impact on low back pain: a prospective randomized controlled trial. Clin J Sport Med 2016; 26: 199–205.
  79. Sedaghati P, Arjmand A, Sedaghati N. Comparison of the effects of different training approaches on dynamic balance and pain intensity in the patients with chronic back pain. Sci J Kurd Univ Med Sci 2017; 22: 45–56.
  80. Segal-Snir Y, Lubetzky VA, Masharawi Y. Rotation exercise classes did not improve function in women with non-specific chronic low back pain: a randomized single blind controlled study. J Back Musculoskelet Rehabil 2016; 29: 467–75.
  81. Se-Hun KIM, Dong-Yel SEO. Effects of a therapeutic climbing program on muscle activation and SF-36 scores of patients with lower back pain. J Phys Ther Sci 2015; 27: 743–6.
  82. Seong Hun YU, Yong Hyeon SIM, Myung Hoon KIM, et al. The effect of abdominal drawing-in exercise and myofascial release on pain, flexibility, and balance of elderly females. J Phys Ther Sci 2016; 28: 2812–5.
  83. Seong-Dae WOO, Tae-Ho KIM. The effects of lumbar stabilization exercise with thoracic extension exercise on lumbosacral alignment and the low back pain disability index in patients with chronic low back pain. J Phys Ther Sci 2016; 28: 680–4.
  84. Shaughnessy M, Caulfield B. A pilot study to investigate the effect of lumbar stabilisation exercise training on functional ability and quality of life in patients with chronic low back pain. Int J Rehabil Res 2004; 27: 297–301.
  85. Sherman KJet al. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med 2011; 171: 2019–26.
  86. Shnayderman I, Katz-Leurer M. An aerobic walking programme versus muscle strengthening programme for chronic low back pain: a randomized controlled trial. Clin Rehabil 2013; 27: 207–14.
  87. Ulger O, Demirel A, Oz M, et al. The effect of manual therapy and exercise in patients with chronic low back pain: double blind randomized controlled trial. J Back Musculoskelet Rehabil 2017; 30: 1303–9.
  88. Unsgaard-Tondel M, Fladmark AM, Salvesen Oyvind, et al. Motor control exercises, sling exercises, and general exercises for patients with chronic low back pain: a randomized controlled trial with 1-year follow-up. Phys Ther 2010; 90: 1426–40.
  89. Vincent HK, Vincent KR, Seay AN, et al. Back strength predicts walking improvement in obese, older adults with chronic low back pain. PM&R 2014; 6: 418–26.
  90. Wajswelner H, Metcalf B, Bennell K. Clinical Pilates versus general exercise for chronic low back pain: randomized trial. Med Sci Sports Exerc 2012; 44: 1197–205.
  91. Williams K, Abildso C, Steinberg L, et al. Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. Spine 2009; 34: 2066–76.
  92. Williams KA, Petronis J, Smith D, et al. Effect of Iyengar yoga therapy for chronic low back pain. Pain 2005; 115: 107–17.
  93. Yi T, Lee J, Lee Y, et al. Comparisons of spinal stabilization exercise and lumbar extensor strengthening exercise in chronic low back pain. J Korean Acad Rehabil Med 2008; 32: 570–5.
  94. Yoo J-H, Kim S-E, Lee M-G, et al. The effect of horse simulator riding on visual analogue scale, body composition and trunk strength in the patients with chronic low back pain. Int J Clin Pract 2014; 68: 941–9.
  95. Young-Dae Y, Yeon-Seop L. The effect of core stabilization exercises using a sling on pain and muscle strength of patients with chronic low back pain. J Phys Ther Sci 2012; 24: 671–4.
  96. Yozbatiran N, Yildirim Y, Parlak B. Effects of fitness and aquafitness exercises on physical fitness in patients with chronic low back pain. The Pain Clinic 2004; 16: 35–42.
  97. Zadro JR, Shirley D, Simic M, et al. Video game–based exercises for older people with chronic low back pain: a randomized Controlledtable trial (GAMEBACK). Phys Ther 2019; 99: 14–27.
  98. Zeada MA. Effects of Pilates on low back pain and urine catecholamine. Ovidus Univ Ann Ser Phys Edu Sport Sci Move Health 2012; 12: 41–7.
  99. Zou L, Zhang Y, Liu Y, et al. The effects of tai chi chuan versus core stability training on lower-limb neuromuscular function in aging individuals with non-specific chronic lower back pain. Medicina 2019; 55 :60.