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Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 164

The effect of exercise programs on pain management and motor control in patients with nonspecific chronic low back pain: A randomized matched subjects trial

Department of Sport Injuries and Corrective Exercises, Faculty of Exercise Sciences, University of Isfahan, Isfahan, Iran

Date of Submission28-Jul-2020
Date of Acceptance07-Dec-2020
Date of Web Publication14-Dec-2021

Correspondence Address:
Vahid Zolaktaf
Department of Sport Injuries and Corrective Exercises, Faculty of Exercise Sciences, University of Isfahan, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpvm.IJPVM_423_20

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Backgroud: Many exercise approaches have been suggested for the treatment of nonspecific chronic low back pain. However, the best exercise approach is still unknown. The purpose of this study was to compare the effect of three exercise approaches based on the Postural Restoration Institute (PRI) and National Academy of Sports Medicine (NASM) on the pain management and motor control of men with nonspecific chronic low back pain. Methods: The study was designed with matched subjects. Thirty-three participants were randomly assigned to three training groups: NASM (n = 11), PRI (n = 11), and NASM-PRI integration (n = 11). Interventions: The participants in each group performed the exercise for eight weeks, three sessions per week and about one hour each session. Pain was measured using a visual analog scale (VAS) scale and functional disability using the Roland–Morris questionnaire. Also, the movement control impairment was measured by the movement control impairment test set. Results: Repeated measures ANOVA showed no significant interaction effect between pain perception, functional disability, and movement control impairment of the groups (P >.05). Conclusions: The findings suggest that different types of exercise rehabilitation were not significantly different on pain reduction, functional disability, and movement control impairment. It is suggested that the participant's preference for an approach should also be considered for encouraging them to adhere to exercise.

Keywords: Exercise, low back pain, movement control

How to cite this article:
Fazel F, Zolaktaf V, Nezhadian SL. The effect of exercise programs on pain management and motor control in patients with nonspecific chronic low back pain: A randomized matched subjects trial. Int J Prev Med 2021;12:164

How to cite this URL:
Fazel F, Zolaktaf V, Nezhadian SL. The effect of exercise programs on pain management and motor control in patients with nonspecific chronic low back pain: A randomized matched subjects trial. Int J Prev Med [serial online] 2021 [cited 2023 Mar 27];12:164. Available from: https://www.ijpvmjournal.net/text.asp?2021/12/1/164/332546

  Introduction Top

Spine-related disorders, specifically chronic low back pain, are a major cause of disability worldwide and a burden on societies.[1],[2] Short-lived disabling back pain has been reported in most people during their lifetime. These episodes of back pain might be recurrent and become chronic.[3] In addition to social and disabling burden of back pain, its economic burden is considerable.[4]

The main cause of chronic low back pain is muscle dysfunction. Muscle dysfunction results in altered motor control leading to improper use of trunk muscles, particularly during voluntary activities.[5] Postural misalignment of the sacroiliac joint is considered a risk factor for lower extremity injury due to its effects on pelvic range of motion. It is also suggested as one of the mechanisms leading to nonspecific low back pain (NSLBP).[6] There are different mechanisms that explain the effect of motor control on pain. This process involves reducing mechanical load and increasing the coordination of muscle control and movement. These changes might be caused by plasticity changes in the cerebral cortex.[7] Exercise and physical activity are effective in improving the health and treatment of musculoskeletal pain. Therefore, exercise and lifestyle should be central to the self-management approach.[8]

Various exercise programs are suggested for the management of NSLBP. The exercises proposed by the National Academy of Sports Medicine (NASM) (focuses on muscular imbalance and motor system)[9] and the Postural Restoration Institute (PRI) (postural adaptive science, asymmetric patterns)[10] are adopted extensively in rehabilitation programs. The aim of the PRI is to discover and explain the science of postural adaptation, asymmetric patterns, and the influence of the polyarticular chains of muscles on the body.[10] In the NASM approach, specific static and dynamic assessments are performed to diagnose muscular imbalances. The obtained results are used to design effective programs based on the continuum of corrective exercises. The continuum of corrective exercises is a four-step, simple, and very effective process that professionals can use to treat common movement disorders.[9]

In this study, we investigated the effect of three integrative exercise approaches based on the PRI and NASM exercises on pain, disability, and movement control impairment of patients with chronic NSLBP caused by discogenic. We aim to find the best approach for managing low back pain cost-effectively as it is a major cause of disability and a burden on social activities.

  Methods Top


This experimental research was designed with a matched subject design. The study was approved by the University of Isfahan Ethical Committee (approval ID: IR.UI.REC.1398.096) and the Iranian Registry of Clinical Trials (IRCT20191214045731N1). The patients suffering from chronic NSLBP were referred by their neurosurgeons and orthopedics to the Center of Exercise Rehabilitation, where the study took place. Patients were men aged between 30 and 50 years old. The tools in Alleyne et al.[11] were used to select the patients with discogenic chronic low back pain as the potential participants. Following the selection process, 33 patients participated in the study based on the following criteria: 1. The occurrence of non-specific chronic back pain diagnosed by a specialist, 2. No medical condition prohibiting the exercises in the study, 3. Time and physical availability to participate in the study, and 4. The absence of any moral opinion forbidding participation. Conditions for exclusion from the study were as follows: 1. Unwillingness to continue participation for any reason; 2. Absent to more than one-third of the training sessions; 3. Failure to adhere to the discipline of the training sessions; and 4. The occurrence of medical problems that prevent performing the exercises.

The matching process was done based on “functional disability” and “pain score.” The participants were randomly assigned to three groups: the NASM group (n = 11), the PRI group (n = 11), and the NASM-PRI group (n = 11). A pretest was conducted and lifestyle change brochures were provided for the participants. Following the pretest, the patients participated in an eight-week exercise intervention. At the end of the research, 25 posttests were performed. [Figure 1] showes the flow of study.
Figure 1: Flow of study

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All the exercise sessions were conducted by two sports specialists, who did not have any experience related to the PRI exercises. The exercise program for the NASM group included low back pain exercises proposed by the NASM [Appendix A].[12] Likewise, participants in the PRI group performed the low back pain exercises recommended by the PRI [Appendix B].[13] For the NASM-PRI group, we designed the self-myofascial releasing exercises based on the theory of the PRI. The exercise regime of the NASM-PRI group is designed based on the four techniques of NASM [Appendix C].

Three variables including pain, functional disability, and motor control impairment were measured by two examiners who were not blinded to group assignment. Pain severity was measured on an 11-point scale (0 to 10), wherein 0 and 10 indicated no pain and severe pain, respectively. The scale was a horizontal 10-cm strip. The patients were asked to look at the scale and specify the amount of pain they felt in the past seven days. This scale has been widely used in research to assess pain, with reported reliability between 0.85 to 0.95 as well as structural validity.[14]

The Roland–Morris Disability Questionnaire was used to measure the level of functional disability. The questionnaire includes 24 statements. To determine the score, the number of marked statements by the participants was summed and divided by the total number of statements (24 points) and then divided by 100. Its reliability is reported to be 0.91 to 0.96 and has structural validity.[9],[14]

Motor dysfunction was measured using the test of movement control impairment.[10] The test consists of six measurements: Waiter's bow (hip flexion in the upright standing position without lumbar region movement: 70–50 degrees flexion), posterior pelvic tilt (active upright standing posture, neutral thoracic vertebrae, and lumbar spine shifts toward flexion), knee extension in sitting position (while sitting in the upright position and keeping lumbar lordosis neutral, extend knee without lumbar region movement: 30–50 degrees of extension is normal), rocking backward and forward in a quadruped position (120 degrees lumbar hip flexion without lumbar region movement when moving pelvic backward and 60 degrees lumbar hip flexion when bending forward), prone lying active knee flexion (active knee flexion at least 90 degrees without movement in lumbar and pelvic), and single-leg stance (the transfer distance between the left and right sides is symmetrical. No more than 2 cm between the sides).

Participants were given a score of 0 if they had no motor control and a score of 1 if they had motor control. The lowest score of motor control impairment (0) and the highest score (6) were reported. In previous studies, the kappa coefficient of this test was reported to be more than 0.6.[15]

The data were analyzed by descriptive statistics and repeated measures ANOVA by SPSS.16 and the level of significance was set at P < 0.05. The Shapiro–Wilk test was used for the normality test.

  Results Top

The demographic properties of the participants are presented in [Table 1]. As shown, there was no significant difference between the demographic properties of the groups (P > 0.05). [Figure 2]a, [Figure 2]b, [Figure 2]c show the line charts of repeated measures ANOVA on three outcome measures of the study. In short, a non-significant interaction effect (P > 0.05) was observed between the three groups in all outcome measures. The eta-squared () coefficients were .06, .04, and .01, respectively, for pain, functional disability, and movement control impairment.
Table 1: Demographic characteristics of the research population participants

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Figure 2: (a) Linear diagram of pain changes, (b) functional disability, (c) movement control impairment in two test times

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The results of the present study shows that intragroup effects were significant (P < 0.05 and F 1,22 ≥ 9.182), intergroup effects were nonsignificant (P ≥ 0.05 and F2,22 ≤ 0.675), and interactive effects were also found nonsignificant (P ≥ 0.05 and F2,22 ≤ 0.716) for pain perception, functional disability, and movement control impairment in three groups [Figure 2]a, [Figure 2]b, [Figure 2]c.

[Figure 2]a, [Figure 2]b, [Figure 2]c clearly show that the slopes of the research groups are approximately similar to each other. In the posttest 1.6, 1.67, and 2.84 increase in the pain score was observed in the PRI, NASM, and NASM-PRI groups, respectively. In addition, functional disability was reduced by 20.42% in the PRI group, 28.71% in the NASM group, and 15.98% in the NASM-PRI group. For movement control impairment, scores were increased by 0.30, 0.50, and 0.44 in PRI, NASM-PRI, and NASM groups, respectively.

  Discussion Top

In this study, pain and functional disability were measured by the visual analog scale and the Roland-Morris questionnaire, respectively. The results of intergroup comparisons showed that pain and functional disability decreased significantly in all three groups after exercise rehabilitation, but there was no significant difference between groups after interactive comparisons.

Several studies reported reduced back pain relief following a workout. In addition, studies have suggested that a variety of exercise protocols have similar effects on pain relief and functional disability improvement. In Miyamoto et al. (2018), all patients received counseling and instructions and were randomly assigned to four groups (74 patients each): 1) Brochure group, 2) Pilates group once a week, 3) Pilates group twice a week, and 4) Pilates group three times a week. Pain and disability were measured six weeks following the intervention. Compared to the brochure group, the Pilates groups showed a significant decrease in pain and functional disability.[15] In a review study by Lin et al. (2016), it was reported that different kinds of exercise programs that focused on lumbar and trunk movements and lasted for 20 hours overall had similar effects on reducing pain and functional disability in people with low back pain.[16]

Paolucci et al. (2019) has suggested that all techniques including pilates, McKenzie, Feldenkrais, and Back Schooling are effective in reducing pain and functional disability and that the techniques have no superiority. Their study examined 14 studies of pilates, six studies of McKenzie exercises, one study of Feldenkrais, three studies of global postural rehabilitation, and two studies of neuromuscular facilitation. The visual analog scale (VAS) and numerical rating scale (NRS) were mainly used to measure the pain. Some studies used the Oswestry scale, the Quebec scale, and the McGill pain questionnaire. In addition, in these studies, the Roland–Morris Questionnaire, the Oswestry Disability Index, the Weddell Disability Index, and the Patient-Specific Functioning Scale were used for the measurement of functional disability.[1]

Shiri et al. (2017) reviewed 13 randomized controlled trials as well as three nonrandomized controlled trials. Their findings suggested that muscle strengthening combined with stretching or aerobic exercise performed two to three times a week is effective in reducing low back pain as well as functional disability improvement.[17]

Another study reported that performing pilates is more effective than minimal physical exercise in reducing low back pain.[18] The authors highlighted that there are not enough studies indicating that pilates exercise is better than the other types of exercises. The effectiveness of pilates in people with low back pain is also reported in another study that assigned 38 subjects to either the experimental group or control group.[19]

In another review study by Saragiotto et al. (2016), no difference between the effects of movement impairment training and other exercise programs on the degree of pain and functional disability reduction in people with low back pain was found. In this review, 13 studies that used a visual analog scale and numerical rating scale to measure pain were examined. The examined studies mainly used the Roland–Morris Questionnaire and the Oswestry Disability Index to measure functional disability.[20]

A review study by Gomes-Neto et al. (2017) suggests that stabilizing exercises did not differ from manual therapy in reducing pain and functional disability. However, stabilizing exercises are significantly different from general exercises in reducing pain and functional disability in patients with low back pain. They investigated 413 studies to evaluate stabilizing exercises, 297 studies for general exercises, and 185 studies for therapy.[21]

In addition, in the present study, movement impairment was measured by the movement impairment test set. According to intragroup comparisons, the results showed that there was a significant improvement in movement dysfunction in all three groups after the eight-week exercise program. No significant difference was observed between the groups after interactive comparison. Our result shows the effectiveness of different exercise rehabilitation protocols on movement dysfunction, although no significant differences were found between different types of exercise rehabilitation protocols in improving movement dysfunction.

Other studies reported improvement in movement control impairment following exercise training and reported that a variety of exercise protocols have similar effects on reducing movement control impairment. In a study, 106 patients with low back pain were divided into two groups—an experimental group of 52 individuals with a specific exercise program focusing on movement impairment and a control group of 54 individuals with general exercise programs that focused on endurance, strength, and spine flexibility. Both groups had a movement impairment score of 3.9 before the intervention. Following the intervention, the experimental group had a score of 1.8 while the control group had a score of 2.8. Both groups recovered and their difference was not statistically significant.[22] In a prospective study, it is shown that personalized exercise programs improved movement dysfunction by 59%, which was statistically significant.[23] In a study conducted by Gutknecht et al., the effect of a combination program including movement control exercises and tactile acuity training on subjects with nonspecific low back pain was investigated. Their results showed that movement impairment had a significant improvement in the pretest phase compared to the posttest phase, but was not significantly different from the control group in a previous study that received only movement control exercises.[24]

In the present study, it was shown that NASM, PRI, and a combination of these two approaches had similar effects on nonspecific chronic low back pain markers. Our results show that exercise can improve chronic NSLBP and that different exercise approaches designed for low back pain have no superiority over each other. Further studies with a larger sample size would be necessary to replicate the present findings. It is important to mention that due to the limited research on the effects of PRI exercise on low back pain, a direct comparison between the results reported here and the previous literature is not possible.

In addition, for encouraging participants to adhere to exercise, patients' preferences should be considered. This consideration optimizes the effects of exercise rehabilitation and inhibits nonspecific chronic low back pain.


The authors sincerely thank the patients for their participation in this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Woolf AD. Controlling the burden of spinal disorders in low-and middle-income countries. Eur Spine J 2018;27:773-5.  Back to cited text no. 3
Mutubuki EN, Luitjens MA, Maas ET, Huygen FJ, Ostelo RW, van Tulder MW, et al. Predictive factors of high societal costs among chronic low back pain patients. Eur J Pain 2020;24:325-37.  Back to cited text no. 4
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White CA. The Effect of PRI Pelvic Repositioning Technique on Innominate Rotation and Hip Range of Motion. The University of North Carolina at Chapel Hill; 2018.  Back to cited text no. 6
Roshini PD, Aseer L, Antony P. Motor control training in chronic low back pain. J Clin Diagn Res 2019;13:YC01-5.  Back to cited text no. 7
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Roland M, Morris R. A study of the natural history of low-back pain. Part II: Development of guidelines for trials of treatment in primary care. Spine 1983;8:145-50.  Back to cited text no. 9
Luomajoki H, Kool J, De Bruin ED, Airaksinen O. Reliability of movement control tests in the lumbar spine. BMC Musculoskelet Disord 2007;8:90.  Back to cited text no. 10
Centre for Effective Practice, Government of Ontario. Clinically Organized Relevant Exam (CORE) Back Tool [Internet]. 2016. Available from: https://cep.health/media/uploaded/CEP_CORE_Back_2016.pdf. [Last accessed on 2020 Jul 25].  Back to cited text no. 11
Clark M, Lucett S. NASM Essentials of Corrective Exercise Training. Lippincott Williams & Wilkins; 2010.  Back to cited text no. 12
Spence H. Case study report: Postural restoration: An effective physical therapy approach to patient treatment. Tech Reg Anesth Pain Manag 2008;12:102-4.  Back to cited text no. 13
Costa LOP, Maher CG, Latimer J, Ferreira PH, Pozzi GC, Ribeiro RN. Psychometric characteristics of the Brazilian-Portuguese versions of the functional rating index and the Roland Morris disability questionnaire. Spine 2007;32:1902-7.  Back to cited text no. 14
Miyamoto GC, Franco KFM, van Dongen JM, dos Santos Franco YR, de Oliveira NTB, Amaral DDV, et al. Different doses of Pilates-based exercise therapy for chronic low back pain: A randomised controlled trial with economic evaluation. Br J Sports Med 2018;52:859-68.  Back to cited text no. 15
Lin HT, Hung WC, Hung JL, Wu PS, Liaw LJ, Chang JH. Effects of pilates on patients with chronic non-specific low back pain: A systematic review. J Phys Ther Sci 2016;28:2961-9.  Back to cited text no. 16
Shiri R, Coggon D, Falah-Hassani K. Exercise for the prevention of low back pain: Systematic review and meta-analysis of controlled trials. Am J Epidemiol 2017;187:1093-101.  Back to cited text no. 17
Patti A, Bianco A, Paoli A, Messina G, Montalto MA, Bellafiore M, et al. Effects of Pilates exercise programs in people with chronic low back pain: A systematic review. Medicine (Baltimore) 2015;94:e383.  Back to cited text no. 18
Patti A, Bianco A, Paoli A, Messina G, Montalto MA, Bellafiore M, et al. Pain perception and stabilometric parameters in people with chronic low back pain after a Pilates exercise program: A randomized controlled trial. Medicine (Baltimore) 2016;95:e2414.  Back to cited text no. 19
Saragiotto BT, Maher CG, Yamato TP, Costa LO, Costa LCM, Ostelo RW, et al. Motor control exercise for nonspecific low back pain: A Cochrane Review. Spine 2016;41:1284-95.  Back to cited text no. 20
Gomes-Neto M, Lopes JM, Conceicao CS, Araujo A, Brasileiro A, Sousa C, et al. Stabilization exercise compared to general exercises or manual therapy for the management of low back pain: A systematic review and meta-analysis. Phys Ther Sport 2017;23:136-42.  Back to cited text no. 21
Saner J, Kool J, Sieben JM, Luomajoki H, Bastiaenen CH, de Bie RA. A tailored exercise program versus general exercise for a subgroup of patients with low back pain and movement control impairment: A randomised controlled trial with one-year follow-up. Man Ther 2015;20:672-9.  Back to cited text no. 22
Luomajoki H, Kool J, de Bruin ED, Airaksinen O. Improvement in low back movement control, decreased pain and disability, resulting from specific exercise intervention. BMC Sports Sci Med Rehabil 2010;2:11.  Back to cited text no. 23
Gutknecht M, Mannig A, Waldvogel A, Wand BM, Luomajoki H. The effect of motor control and tactile acuity training on patients with non-specific low back pain and movement control impairment. J Bodyw Mov Ther 2015;19:722-31.  Back to cited text no. 24


  [Figure 1], [Figure 2]

  [Table 1]


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