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DOI: 10.1016/j.bjpt.2018.11.006
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Evidence of stabilizing exercises for low back- and pelvic girdle pain – a critical review
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Britt Stuge
Corresponding author
britt.stuge@medisin.uio.no

Correspondence address: Division of Orthopaedic Surgery, Oslo University Hospital, Bygg 72, 2. etg, Pb. 4956 Nydalen, 0424 Oslo, Norway.
Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
Highlights

  • The evidence of core stabilization exercises is controversial.

  • Exercises need to be understood in the bio-psycho-social context.

  • Individually tailor the exercises to the patient's needs and capability.

  • Adherence might increase when the patients understand the aim of the exercises.

  • Exercises need to guided and supervised to secure performance and quality.

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Abstract
Background

Pregnancy-related low back pain (LBP) and pelvic girdle pain (PGP) have been associated with an alteration in the strategy for lumbopelvic stabilization. Different core stabilization approaches exist, the evidence is however controversial.

Methods

This paper discusses how to improve the evidence of exercises for women suffering from LBP and PGP during and after pregnancy. Exercises should be understood in a context, where the bio-psycho-social perspective directs the prescription of exercises, targeting both psychological and physical factors. The type of exercise probably should be individually tailored to the needs and capability of the individual and it is not only about the most appropriate exercise, it is about dosage and delivery of the exercises, and it is about performance. To promote adherence the use of patient preferences, with self-defined movement goals, may be a motivational basis for behavior change. Communication skills may facilitate positive beliefs and provide a motivational foundation for empowerment, self-efficacy and for self-management. To learn by discovery where the patient learns through their own experiences, might motivate the patients to active engagement and to behavioral change. Adherence probably will increase when the patients understand the aim and the rationale behind the exercises they are prescribed. However, with high adherence to exercises that maintains an inappropriate motor pattern, LBP and PGP possibly could proceed into chronicity.

Conclusion

Exercises need to be meaningful to the patient, relevant for daily activities, individualized according to patient preferences, guided and supervised to secure performance and quality.

Keywords:
Low back pain
Pelvic girdle pain
Exercises
Individualization
Physical therapy
Rehabilitation
Full Text
Introduction

Women with low back pain (LBP) and pelvic girdle pain (PGP) report a significantly lower health-related quality of life than that reported by healthy women.1,2 A major factor affecting the women's quality of life is lack of physical ability and a greater loss of physical condition seems to be not a cause but rather a consequence of LBP and PGP in pregnancy.3 Although exercise is recommended during pregnancy, pregnant women are tending to reduce their levels of physical activity.4,5 Whereas most women recover after delivery, a number of women continue living with disabling PGP for months and years. Discouragement, isolation and loneliness may be part of women's lives with pain and limited physical activity.6

LBP is usually defined as pain between the twelfth rib and the gluteal fold,7 whereas PGP is defined as pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints.8 Even though similar and overlapping features may be ascribed to LBP and to PGP, it is maintained that a distinction should be made.8,9 PGP generally arises in relation to pregnancy and is reported to be the most common condition, affecting 50% of the symptomatic patients. LBP affects about one-third and one-sixth report PGP and LBP combined.10 Women with PGP experience more intense pain and greater disability than women with LBP in pregnancy.11,12

The etiology and pathogenesis of PGP is unclear and probably multifactorial, including psychosocial factors. Underlying causes may include hormonal and biomechanical aspects, inadequate motor control and stress on ligament structures.13 Increased shear forces across the pelvic joints have been suggested to be one factor for pain in women with PGP.8 The pelvis serves to transfer load from the trunk to the legs, and for the load to be effectively transferred and for the shear forces to be minimized across the joints, the pelvis needs to be stabilized. An impaired load transfer during activities may result in overload of the ligaments of the pelvis and hence have an influence on PGP.14,15 Changes in spinal curvature and posture may be caused by pregnancy and both increased lumbar lordosis16 and a flattening of the lumbar spine or a lumbar kyphosis is reported to be prevalent during pregnancy.17,18 Frequent or sustained pain-provoking postures and movements might influence the pelvic ligaments and in turn link to other symptoms.

PGP have been associated with an alteration in the strategy for lumbopelvic stabilization with insufficient as well as excessive motor activation of the lumbopelvic and surrounding musculature.19 Hence, impaired motor control patterns may be a possible mechanism for ongoing pain and disability in patients with persistent PGP.20 Also, positive changes in motor control have been found to be associated with relief of pain and disability.21,22 While the role of muscle function in LBP in the general population is debated, an association between reduced muscle function and LBP and/or PGP in pregnant women is reported.23 In pregnant women with LBP and/or PGP, both lower levels of trunk muscle endurance and hip extension muscle strength24 and increased muscle activity during the active straight leg raise test are reported.25 Consequently, an association between muscle dysfunction and LBP and PGP during and after pregnancy may exist.

Specific exercises for motor control and stability have been recommended for PGP postpartum.8 The level of evidence is, however, limited, as few randomized controlled trials have been performed. The effectiveness of motor control and stability exercises for the treatment of LBP and PGP postpartum has been investigated in one systematic review.26 Different interventions were compared and with no firm conclusion of evidence.22,27–29 Also, group fitness classes for pregnant women showed in a randomized controlled trial no effect on the prevalence of LBP and PGP during pregnancy or postpartum.30

Despite limited evidence of effect, core stabilization exercises have grown in popularity31 and different core stabilization approaches exist.32,33 Exercises on unstable surfaces, as illustrated in Fig. 1, is an example of a stabilizing exercise commonly used and prescribed for LBP and PGP in many countries over the last years. We may however question: Why are patients recommended such exercises? What is the aim of the exercise? Does it help for LBP and PGP? What about the quality of the exercise? Does performance matter? Furthermore, do patients adhere to such exercises and will adherence to exercises be sufficient for reducing LBP and PGP? Finally, what about the evidence?

Figure 1.
(0.07MB).

Example of a core stabilizing exercise.

ExercisesEvidence of exercises

Exercise may be defined as physical activity that is planned, structured, and repetitive for the purpose of conditioning any part of the body. Exercise is used to improve health, maintain fitness and is important as a means of physical rehabilitation.34 Supervised exercise therapy has been recommended as first-line treatment for chronic LBP the last 10 years.35 Still, evidence show that exercise therapy only has moderate effect on LBP, no clear evidence of effect on PGP, and it seems like one form of exercise is not superior to other forms of exercises.36–41 However, the last decade stabilizing exercises or motor control exercises has blamed over us worldwide as the choice of optimal exercises for LBP and PGP. Stabilizing exercises has been referred to as exercise interventions that aim to improve function of specific trunk muscles thought to control inter-segmental movement of the spine and enable the patient to regain control and coordination of the spine and pelvis using principles of motor learning.42 Core stabilizing exercises has for years been the focus for researchers, fitness centers, patients and for clinicians. Although stabilizing exercises have become very popular, the evidence is controversial. Some recent reviews conclude that stabilization exercises are more effective than general exercise, while others state the opposite.43–46 Hence, even core stabilization exercises do not give convincing evidence of effect. However, an agreed definition of core stabilization exercises does not exist.

Aim of the exercise

The internationally endorsed Consensus on Exercise Reporting Template (CERT) is a 16-item checklist to improve the reporting of exercise programs and hopefully also the design and implementation of exercise programs.47,48 The CERT has recently shown to have good inter-rater agreement and to comprehensively evaluate reporting of exercise interventions.49 The checklist contains the following 7 categories: materials (what), provider (who), delivery (how), location (where), dosage (when, how much), tailoring (what, how) and compliance (how well/planned and actual). However, as commented by the authors of the CERT an explicit statement of the aim of the exercise, ‘why’ is missing.50 The aim of an exercise probably will influence on the design and the outcomes of an exercise intervention, and the aim of the exercise might be of significant importance for the patient's motivation and hence on adherence.

Consequently, what are the aim and the relevance of stabilizing exercises standing on unstable surfaces? An exercise standing on unstable surfaces, such as in Fig. 1, could be labeled a stabilizing exercise or a motor control exercise. Definitely, subjects standing on unstable surfaces have to activate muscles not to fall off, but is it necessarily an optimal motor control exercise? Could the performance of the exercise be maladaptive to the women's pain behaviors and complaints? Increased co-contraction with hyperactivity of core muscles and excessively guarded spinal movement with inability to relax spinal muscles are reported among LBP patients.51,52 Hence, the value of core stability exercises that promote bracing or excessively increasing trunk muscle activation could be questioned.53 It could also be questioned whether the women illustrated in Fig. 1 are doing the same exercise with similar motor pattern and similar to what is shown by the instructor? Or is it likely that they use different motor patterns? If increased activity of the extensor muscles and a lumbar lordosis increase the LBP for a woman, would we expect an exercise where this motor pattern is maintained, to reduce the woman's LBP? Opposite, if a flexion pattern provokes PGP for a woman will an exercise where she sustains a flexion pattern be a good exercise for her PGP? Probably not.

There is a lack of evidence linking the effects of exercise in LBP to changes in the musculoskeletal system,54,55 but performance of an exercise may result in increased pain or in persistence of pain.56 Quality and performance of exercises are considered as important aspects in reducing LBP and PGP.48,57 Inappropriate exercise can do more harm than good, with the definition of inappropriate varying according to the individual. Subsequently, what about high adherence to inappropriate exercises? It might be that the women stop exercising because they do not understand why they should do the exercise or because it does not reduce their LBP and PGP? And maybe they should be advised to stop, because the exercise maintains their inappropriate motor pattern. Stabilizing exercises could also create negative cognitions about instability and increase fear-avoidance.50

Individualization and adherence

Exercises should be understood in a context, where the bio-psycho-social perspective guides the prescription of exercises, targeting both psychological and physical factors.58 The type of exercise probably should be individually tailored to the needs and abilities of the individual, and it is not only about the most appropriate exercise, it's about dosage (frequency, duration, intensity) and delivery (group, individualized, home-based) of the exercises.36,40,48 And it's about quality (performance, supervision) of the exercise, how are the exercises performed, do the patient need to be supervised?

One randomized controlled trial has shown significant and long-lasting positive effects of a treatment program for postpartum PGP, including stabilizing exercises.2,22 Why did this study show positive effects? This was an individualized and multidimensional treatment program focusing motor control and functional exercises, and necessarily integrated cognitive aspects within a bio-psycho-social framework. The exercises focused gradually progression of motor control and strength, performed without provoking pain, which has been shown to be important for adherence.59 Furthermore, the aim of the exercises had a functional approach based on the women's needs. The women learned to normalize pain provocative daily life activities, postures and movements to avoid flare-ups of pain.

The exercises were individualized and supervised. The aim of the exercise was clear to the patient (whether it was about control, strength or endurance), and performance (how) with relaxation to avoid muscle guarding was emphasized. An exercise diary was used for dosage and to show progression; consequently to increase motivation and adherence, and adherence was surprisingly high. Despite a busy life taking care of children, suffering from persistent pain postpartum, the women reported accomplishing on average 80% of their home based exercise program. And why was that? Adherence is very much about the way the exercises are provided.60 To promote adherence the use of patient preferences, with self-defined movement goals, may be a motivational basis for behavior change.53,60 Other important components are implementation (individually designed, supervised, home based exercises) and performance feedback (correcting movement patterns). Furthermore, communication skills may facilitate positive beliefs and provide a motivational foundation for empowerment, self-efficacy and for self-management and empowerment.61–63

The updated LBP guidelines from the National Institute for Health and Care Excellence (NICE) show a clear emphasis on facilitating self-management strategies.64 The guideline suggests that patient's needs, preferences and capability should be taken into account. It is of significant importance that health care providers not consider themselves as experts or teachers and consider the patients as ‘empty bottles’. Learning by Discovery65,66 encourages active engagement, promotes motivation, and promotes autonomy, responsibility and independence. It develops creativity and problem solving skills and tailoring learning experiences. To learn by discovery hopefully will motivate the patients to active engagement and to behavioral change. The patient learns through their own experiences. For example when a patient reports pain while standing, guiding them to change position and then question if the change influenced on their pain, and if it did, the patient discovers a difference, which probably will motivate them to perform changes during daily life and while performing exercises. In other words, the design of an exercise program probably will influence on program effectiveness.

Design of exercise studies

Today there is a wide variation among studies in how exercises are named and implemented and because most trials do not adequately report intervention details, information can be difficult to obtain.49 When comparing exercise therapy, we might question why studies show controversial results? It could be, because we are comparing ‘apples and pears’? In a study by Macedo et al.,38 it is shown that two studies, by O'Sullivan et al.67 and Stuge et al.,2,22 showed significant and long-term effect of an exercise intervention. What do these two studies have in common? First of all, they included sub-groups of LBP and PGP. Both studies also focused individual exercises incorporated into functionally daily life activities that commonly aggravated the patients’ symptoms, and the exercises were supervised and delivered as home exercises on daily basis.

It has been shown that therapy that is specifically directed at well-defined sub-groups leads to improved effectiveness of interventions.68 Lumping heterogeneous LBP and PGP patients into an exercise study will help in getting sufficient power for the study, but will a “one-size-fits-all” approach be optimal treatment for the individual patient?68,69 It could be questioned whether unidimensional care such as a “stay active” approach will target underlying mechanisms of LBP and PGP? The most effective exercise therapy to improve pain and function in chronic LBP has shown to be individually designed treatment programs that were supervised and delivered as home exercise with regular therapist follow-up to encourage adherence.36 Adherence probably will increase when the patients understand the aim and the rationale behind the individual exercise they are prescribed, but are adherence enough?

With high adherence to exercises that maintains an inappropriate motor pattern, LBP and PGP possibly could proceed into chronicity. Exercises might be labeled motor control exercises, but with an inappropriate performance it may result in stiffness and rigidity, quite commonly seen in patients doing stabilizing exercises. Increased co-contraction of trunk stabilizing muscles during tasks that provoke pain and an inability to relax muscles are reported in both LBP and in PGP.70,71 The exercises may be more about strength than about motor control. Patients may comply with their prescribed exercises; they get strong, but also stiff and rigid and with no improvement in pain and function. Neuromuscular control or core stability is needed to perform daily life activities, but only low levels of muscle contraction are needed to stabilize the spine.72 So, when are patients strong enough? Is it a good choice to continue doing the same exercises when the exercises do not reduce LBP and PGP? Furthermore, which muscles do we need to strengthen?

Bending and lifting are daily functional activities which may be challenging for patients with LBP and PGP. The quadriceps muscle was paid attention to years ago where rehabilitation of low-back-injured workers focused the quadriceps muscles,73,74 and recent studies highlight exercises incorporated into functional tasks.75–77 Most functional tasks involve the use of lower extremities, however it is often seen that women with PGP adapt to an inappropriate motor pattern where they, e.g. reduce using their lower extremities and compensate with the arms when standing up and sitting down on a chair. So, maybe the essential exercise for LBP and PGP is to primarily strengthen the lower extremities, thighs and buttocks? The quadriceps muscle exertion is the weak link for the squat technique74 and squats can be performed as home based exercises incorporated into functional tasks. Not all patients with LBP and PGP will however, benefit equally from exercises,78,79 hence patients should be encouraged to engage in regular exercises they personally enjoy with self-identified functional goals and meaningful movements.53

Conclusion

In conclusion, to increase from moderate to strong evidence of exercises, adherence of exercises is essential. To enhance adherence, exercises need to be meaningful to the patient, relevant for daily activities, individualized according to patient preferences, guided and supervised to secure performance and quality. Speak to the patient's heart and brain and tell them to practice what ‘they want to be good at, and no exercise is better than the way it is performed. Maybe, if mentioned aspects are taken into consideration, future randomized controlled trials will show strong effect of exercise programs for LBP and PGP.

Conflicts of interest

The author declares no conflicts of interest.

References
[1]
C. Olsson, L. Nilsson-Wikmar
Health-related quality of life and physical ability among pregnant women with and without back pain in late pregnancy
Acta Obstet Gynecol Scand, 83 (2004), pp. 351-357
[2]
B. Stuge, M.B. Veierød, E. Lærum, N. Vøllestad
The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy. A two-year follow-up of a randomized clinical trial
Spine (Phila Pa 1976), 29 (2004), pp. E197-E203
[3]
E. Thorell, P. Kristiansson
Pregnancy related back pain, is it related to aerobic fitness? A longitudinal cohort study
BMC Pregnancy Childbirth, 12 (2012), pp. 30 http://dx.doi.org/10.1186/1471-2393-12-30
[4]
D.B. Fell, K.S. Joseph, B.A. Armson, L. Dodds
The impact of pregnancy on physical activity level
Matern Child Health J, 13 (2009), pp. 597-603 http://dx.doi.org/10.1007/s10995-008-0404-7
[5]
K.M. Owe, W. Nystad, K. Bo
Correlates of regular exercise during pregnancy: the Norwegian Mother and Child Cohort Study
Scand J Med Sci Sports, 19 (2009), pp. 637-645 http://dx.doi.org/10.1111/j.1600-0838.2008.00840.x
[6]
J. Engeset, B. Stuge, L. Fegran
Pelvic girdle pain affects the whole life – a qualitative interview study in Norway on women's experiences with pelvic girdle pain after delivery
BMC Res Notes, 7 (2014), pp. 686 http://dx.doi.org/10.1186/1756-0500-7-686
[7]
C.E. Dionne, K.M. Dunn, P.R. Croft
A consensus approach toward the standardization of back pain definitions for use in prevalence studies
Spine (Phila Pa 1976), 33 (2008), pp. 95-103
[8]
A. Vleeming, H.B. Albert, H.C. Ostgaard, B. Sturesson, B. Stuge
European guidelines for the diagnosis and treatment of pelvic girdle pain
Eur Spine J, 17 (2008), pp. 794-819 http://dx.doi.org/10.1007/s00586-008-0602-4
[9]
H.C. Ostgaard, G. Zetherstrom, E. Roos-Hansson, B. Svanberg
Reduction of back and posterior pelvic pain in pregnancy
Spine (Phila Pa 1976), 19 (1994), pp. 894-900
[10]
W.H. Wu, O.G. Meijer, K. Uegaki
Pregnancy-related pelvic girdle pain (PPP), I: terminology, clinical presentation, and prevalence
Eur Spine J, 13 (2004), pp. 575-589 http://dx.doi.org/10.1007/s00586-003-0615-y
[11]
A. Gutke, H.C. Ostgaard, B. Oberg
Pelvic girdle pain and lumbar pain in pregnancy: a cohort study of the consequences in terms of health and functioning
Spine (Phila Pa 1976), 31 (2006), pp. E149-E155
[12]
H.S. Robinson, A.M. Mengshoel, E.K. Bjelland, N.K. Vollestad
Pelvic girdle pain, clinical tests and disability in late pregnancy
[13]
P.B. O'Sullivan, D.J. Beales
Diagnosis and classification of pelvic girdle pain disorders. Part 2: illustration of the utility of a classification system via case studies
[14]
C.J. Snijders, A. Vleeming, R. Stoeckart
Transfer of lumbosacral load to iliac bones and legs. 1. Biomechanics of self-bracing of the sacroiliac joints and its significance for treatment and exercise
Clin Biomech (Bristol, Avon), 8 (1993), pp. 285-294
[15]
P.H. Eichenseer, D.R. Sybert, J.R. Cotton
A finite element analysis of sacroiliac joint ligaments in response to different loading conditions
Spine (Phila Pa 1976), 36 (2011), pp. E1446-E1452
[16]
M.E. Franklin, T. Conner-Kerr
An analysis of posture and back pain in the first and third trimesters of pregnancy
J Orthop Sports Phys Ther, 28 (1998), pp. 133-138 http://dx.doi.org/10.2519/jospt.1998.28.3.133
[17]
K. Moore, G.A. Dumas, J.G. Reid
Postural changes associated with pregnancy and their relationship with low-back pain
Clin Biomech (Bristol, Avon), (1990), pp. 169-174
[18]
N. Okanishi, N. Kito, M. Akiyama, M. Yamamoto
Spinal curvature and characteristics of postural change in pregnant women
Acta Obstet Gynecol Scand, 91 (2012), pp. 856-861 http://dx.doi.org/10.1111/j.1600-0412.2012.01400.x
[19]
P.B. O'Sullivan, D.J. Beales
Diagnosis and classification of pelvic girdle pain disorders – Part 1: a mechanism based approach within a biopsychosocial framework
[20]
D.J. Beales, P.B. O'Sullivan, N.K. Briffa
Motor control patterns during an active straight leg raise in chronic pelvic girdle pain subjects
Spine (Phila Pa 1976), 34 (2009), pp. 861-870
[21]
P.B. O'Sullivan, D.J. Beales
Changes in pelvic floor and diaphragm kinematics and respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention: a case series
[22]
B. Stuge, E. Lærum, G. Kirkesola, N. Vøllestad
The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy. A randomized controlled trial
Spine (Phila Pa 1976), 29 (2004), pp. 351-359
[23]
G.A. Dumas, A. Leger, A. Plamondon, K.M. Charpentier, A. Pinti, M. McGrath
Fatigability of back extensor muscles and low back pain during pregnancy
Clin Biomech (Bristol, Avon), 25 (2010), pp. 1-5
[24]
A. Gutke, H.C. Ostgaard, B. Oberg
Association between muscle function and low back pain in relation to pregnancy
J Rehabil Med, 40 (2008), pp. 304-311 http://dx.doi.org/10.2340/16501977-0170
[25]
G.M. de, A.L. Pool-Goudzwaard, C.W. Spoor, C.J. Snijders
The active straight leg raising test (ASLR) in pregnant women: differences in muscle activity and force between patients and healthy subjects
[26]
C.W. Ferreira, F. Alburquerque-Sendin
Effectiveness of physical therapy for pregnancy-related low back and/or pelvic pain after delivery: a systematic review
Physiother Theory Pract, 29 (2013), pp. 419-431 http://dx.doi.org/10.3109/09593985.2012.748114
[27]
J.M. Mens, C.J. Snijders, H.J. Stam
Diagonal trunk muscle exercises in peripartum pelvic pain: a randomized clinical trial
Phys Ther, 80 (2000), pp. 1164-1173
[28]
C.H. Bastiaenen, R.A. de Bie, J.W. Vlaeyen
Long-term effectiveness and costs of a brief self-management intervention in women with pregnancy-related low back pain after delivery
BMC Pregnancy Childbirth, 8 (2008), pp. 19 http://dx.doi.org/10.1186/1471-2393-8-19
[29]
A. Gutke, J. Sjodahl, B. Oberg
Specific muscle stabilizing as home exercises for persistent pelvic girdle pain after pregnancy: a randomized, controlled clinical trial
J Rehabil Med, 42 (2010), pp. 929-935 http://dx.doi.org/10.2340/16501977-0615
[30]
L.A. Haakstad, K. Bo
Effect of a regular exercise programme on pelvic girdle and low back pain in previously inactive pregnant women: a randomized controlled trial
J Rehabil Med, 47 (2015), pp. 229-234 http://dx.doi.org/10.2340/16501977-1906
[31]
S.D. Liddle, B.G. David, J.H. Gracey
Physiotherapists’ use of advice and exercise for the management of chronic low back pain: a national survey
[32]
P. Bruno
The use of “stabilization exercises” to affect neuromuscular control in the lumbopelvic region: a narrative review
J Can Chiropr Assoc, 58 (2014), pp. 119-130
[33]
J. Brumitt, J.W. Matheson, E.P. Meira
Core stabilization exercise prescription, part I: current concepts in assessment and intervention
Sports Health, 5 (2013), pp. 504-509 http://dx.doi.org/10.1177/1941738113502451
[34]
C.E. Garber, B. Blissmer, M.R. Deschenes
American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise
Med Sci Sports Exerc, 43 (2011), pp. 1334-1359 http://dx.doi.org/10.1249/MSS.0b013e318213fefb
[35]
O. Airaksinen, J.I. Brox, C. Cedraschi
Chapter 4 European guidelines for the management of chronic nonspecific low back pain
Eur Spine J, 15 (2006), pp. S192-S300 http://dx.doi.org/10.1007/s00586-006-1072-1
[36]
J.A. Hayden, M.W. van Tulder, G. Tomlinson
Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain
Ann Intern Med, 142 (2005), pp. 776-785
[37]
P.H. Ferreira, M.L. Ferreira, C.G. Maher, R.D. Herbert, K. Refshauge
Specific stabilisation exercise for spinal and pelvic pain: a systematic review
Aust J Physiother, 52 (2006), pp. 79-88
[38]
L.G. Macedo, R.J. Smeets, C.G. Maher, J. Latimer, J.H. McAuley
Graded activity and graded exposure for persistent nonspecific low back pain: a systematic review
Phys Ther, 90 (2010), pp. 860-879 http://dx.doi.org/10.2522/ptj.20090303
[39]
B.T. Saragiotto, C.G. Maher, T.P. Yamato
Motor control exercise for chronic non-specific low-back pain
Cochrane Database Syst Rev, (2016), pp. CD012004
[40]
R. Shiri, D. Coggon, K. Falah-Hassani
Exercise for the prevention of low back and pelvic girdle pain in pregnancy: a meta-analysis of randomized controlled trials
Eur J Pain, 22 (2018), pp. 19-27 http://dx.doi.org/10.1002/ejp.1096
[41]
M. O’Keeffe, A. Hayes, K. McCreesh, H. Purtill, K. O'Sullivan
Are group-based and individual physiotherapy exercise programmes equally effective for musculoskeletal conditions? A systematic review and meta-analysis
Br J Sports Med, 51 (2017), pp. 126-132 http://dx.doi.org/10.1136/bjsports-2015-095410
[42]
J.A. Hides, G.A. Jull, C.A. Richardson
Long-term effects of specific stabilizing exercises for first-episode low back pain
Spine (Phila Pa 1976), 26 (2001), pp. E243-E248
[43]
X.Q. Wang, J.J. Zheng, Z.W. Yu
A meta-analysis of core stability exercise versus general exercise for chronic low back pain
[44]
M.G. Bystrom, E. Rasmussen-Barr, W.J. Grooten
Motor control exercises reduces pain and disability in chronic and recurrent low back pain: a meta-analysis
Spine (Phila Pa 1976), 38 (2013), pp. E350-E358
[45]
B.E. Smith, C. Littlewood, S. May
An update of stabilisation exercises for low back pain: a systematic review with meta-analysis
BMC Musculoskelet Disord, 15 (2014), pp. 416 http://dx.doi.org/10.1186/1471-2474-15-416
[46]
M. Gomes-Neto, J.M. Lopes, C.S. Conceicao
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, 23 (2017), pp. 136-142 http://dx.doi.org/10.1016/j.ptsp.2016.08.004
[47]
S.C. Slade, C.E. Dionne, M. Underwood
Consensus on Exercise Reporting Template (CERT): modified Delphi study
Phys Ther, 96 (2016), pp. 1514-1524 http://dx.doi.org/10.2522/ptj.20150668
[48]
S.C. Slade, C.E. Dionne, M. Underwood, R. Buchbinder
Consensus on Exercise Reporting Template (CERT): explanation and elaboration statement
Br J Sports Med, 50 (2016), pp. 1428-1437 http://dx.doi.org/10.1136/bjsports-2016-096651
[49]
S.C. Slade, S. Finnegan, C.E. Dionne, M. nderwood, R. uchbinder
The Consensus on Exercise Reporting Template (CERT) applied to exercise interventions in musculoskeletal trials demonstrated good rater agreement and incomplete reporting
J Clin Epidemiol, (2018),
pii: S0895-4356(18)30088-X
[50]
P. Kent, P.B. O'Sullivan, J. Keating, S.C. Slade
Evidence-based exercise prescription is facilitated by the Consensus on Exercise Reporting Template (CERT)
Br J Sports Med, 52 (2018), pp. 147-148 http://dx.doi.org/10.1136/bjsports-2016-097405
[51]
W. Dankaerts, P. O'Sullivan, A. Burnett, L. Straker, P. Davey, R. Gupta
Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model
Spine (Phila Pa 1976), 34 (2009), pp. 1610-1618
[52]
S. Lewis, P. Holmes, S. Woby, J. Hindle, N. Fowler
Changes in muscle activity and stature recovery after active rehabilitation for chronic low back pain
[53]
P. Stilwell, K. Harman
Contemporary biopsychosocial exercise prescription for chronic low back pain: questioning core stability programs and considering context
J Can Chiropr Assoc, 61 (2017), pp. 6-17
[54]
F. Steiger, B. Wirth, E.D. de Bruin, A.F. Mannion
Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review
Eur Spine J, 21 (2012), pp. 575-598 http://dx.doi.org/10.1007/s00586-011-2045-6
[55]
A.Y. Wong, E.C. Parent, M. Funabashi, G.N. Kawchuk
Do changes in transversus abdominis and lumbar multifidus during conservative treatment explain changes in clinical outcomes related to nonspecific low back pain? A systematic review
[56]
L.V. Lima, T.S.S. Abner, K.A. Sluka
Does exercise increase or decrease pain? Central mechanisms underlying these two phenomena
J Physiol, 595 (2017), pp. 4141-4150 http://dx.doi.org/10.1113/JP273355
[57]
M. Friedrich, T. Cermak, P. Maderbacher
The effect of brochure use versus therapist teaching on patients performing therapeutic exercise and on changes in impairment status
Phys Ther, 76 (1996), pp. 1082-1088
[58]
A. Hall, H. Richmond, B. Copsey
Physiotherapist-delivered cognitive-behavioural interventions are effective for low back pain, but can they be replicated in clinical practice? A systematic review
Disabil Rehabil, 40 (2018), pp. 1-9 http://dx.doi.org/10.1080/09638288.2016.1236155
[59]
K. Jack, S.M. McLean, J.K. Moffett, E. Gardiner
Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review
[60]
E. Aboagye
Valuing individuals’ preferences and health choices of physical exercise
[61]
C. Lonsdale, A.M. Hall, A. Murray
Communication skills training for practitioners to increase patient adherence to home-based rehabilitation for chronic low back pain: results of a Cluster Randomized Controlled Trial
Arch Phys Med Rehabil, 98 (2017), pp. 1732-1743 http://dx.doi.org/10.1016/j.apmr.2017.02.025
[62]
P.J.A. Nicolson, K.L. Bennell, F.L. Dobson, G.A. Van, M.A. Holden, R.S. Hinman
Interventions to increase adherence to therapeutic exercise in older adults with low back pain and/or hip/knee osteoarthritis: a systematic review and meta-analysis
Br J Sports Med, 51 (2017), pp. 791-799 http://dx.doi.org/10.1136/bjsports-2016-096458
[63]
B. Stuge, A. Bergland
Evidence and individualization: important elements in treatment for women with postpartum pelvic girdle pain
Physiother Theory Pract, 27 (2011), pp. 557-565 http://dx.doi.org/10.3109/09593985.2010.551802
[64]
NICE
Low Back Pain and Sciatica in Over 16s: Assessment and Management
National Institute for Health and Care Excellence: Clinical Guideline, (2016)
[65]
J.S. Bruner
The act of discovery
Harv Educ Rev, 31 (1961), pp. 21-32
[66]
J.S. Bruner
The Process of Education
Harvard University Press, (2009)
[67]
P.B. O'Sullivan, G.D. Phyty, L.T. Twomey, G.T. Allison
Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis
Spine (Phila Pa 1976), 22 (1997), pp. 2959-2967
[68]
N.V. Karayannis, G.A. Jull, P.W. Hodges
Physiotherapy movement based classification approaches to low back pain: comparison of subgroups through review and developer/expert survey
BMC Musculoskelet Disord, 13 (2012), pp. 24 http://dx.doi.org/10.1186/1471-2474-13-24
[69]
N.E. Foster, J.C. Hill, E.M. Hay
Subgrouping patients with low back pain in primary care: are we getting any better at it?
[70]
W. Dankaerts, P. O'Sullivan
The validity of O'Sullivan's classification system (CS) for a sub-group of NS-CLBP with motor control impairment (MCI): overview of a series of studies and review of the literature
[71]
B. Stuge, K. Saetre, H.B. Ingeborg
The automatic pelvic floor muscle response to the active straight leg raise in cases with pelvic girdle pain and matched controls
Man Ther, 18 (2013),
[72]
E. Lederman
The myth of core stability
J Bodyw Mov Ther, 14 (2010), pp. 84-98 http://dx.doi.org/10.1016/j.jbmt.2009.08.001
[73]
J.H. Trafimow, O.D. Schipplein, G.J. Novak, G.B. Andersson
The effects of quadriceps fatigue on the technique of lifting
Spine (Phila Pa 1976), 18 (1993), pp. 364-367
[74]
K.B. Hagen, K. Harms-Ringdahl
Ratings of perceived thigh and back exertion in forest workers during repetitive lifting using squat and stoop techniques
Spine (Phila Pa 1976), 19 (1994), pp. 2511-2517
[75]
P. O'Sullivan
Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism
[76]
K.V. Fersum, W. Dankaerts, P.B. O'Sullivan
Integration of subclassification strategies in randomised controlled clinical trials evaluating manual therapy treatment and exercise therapy for non-specific chronic low back pain: a systematic review
Br J Sports Med, 44 (2010), pp. 1054-1062 http://dx.doi.org/10.1136/bjsm.2009.063289
[77]
K. O'Sullivan, W. Dankaerts, L. O'Sullivan, P.B. O'Sullivan
Cognitive functional therapy for disabling nonspecific chronic low back pain: multiple case–cohort study
Phys Ther, 95 (2015), pp. 1478-1488 http://dx.doi.org/10.2522/ptj.20140406
[78]
G.E. Hicks, J.M. Fritz, A. Delitto, S.M. McGill
Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program
Arch Phys Med Rehabil, 86 (2005), pp. 1753-1762 http://dx.doi.org/10.1016/j.apmr.2005.03.033
[79]
N.E. Foster, J.R. Anema, D. Cherkin
Prevention and treatment of low back pain: evidence, challenges, and promising directions

This paper is part of a Special Issue on Women's Health Physical Therapy.

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Brazilian Journal of Physical Therapy

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