Effect of core stability exercises on postpartum lumbopelvic pain A randomized controlled trial (1)

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Journal of Back and Musculoskeletal Rehabilitation -1 (2018) 1–9 1
DOI 10.3233/BMR-181259
IOS Press
Effect of core stability exercises on
postpartum lumbopelvic pain: A randomized
controlled trial
Marwa Shafiek Mustafa Saleha,∗, Afaf Mohamed Mahmoud Botlab and
Noran Ahmed Mohammed Elbeharya
aDepartment of Basic Science for Physical Therapy, Faculty of Physical Therapy, Cairo University, Egypt
bDepartment of Women’s Health, Faculty of Physical Therapy, Cairo University, Egypt
Abstract.
BACKGROUND: Core stability exercises have been widely advocated for management of patients with different musculoskele-
tal conditions, even though its effect on postpartum lumbopelvic pain (LPP) has not been fully investigated.
OBJECTIVE: This study was conducted to investigate the effect of core stability exercises on postpartum LPP.
METHODS: Thirty four women suffering from postpartum LPP were randomly assigned to the study or control group. The
control group (n = 17) received infrared radiation and continuous ultrasound on lumbosacral region (L1-S5), whereas the study
group (n = 17) received core stability exercises in addition to infrared radiation and continuous ultrasound three sessions a week
for six weeks. Pain Pressure Threshold (PPT), Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) were assessed
for all participants in both groups before and after the treatment program.
RESULTS: There was a significant improvement in PPT, VAS and ODI post-treatment compared with the pre-treatment in both
groups (p = 0.001). There was a significant improvement in participants who received core stability exercises as compared to
participants treated with the traditional treatment in PPT (P = 0.001), VAS (P = 0.001) and ODI (P = 0.009).
CONCLUSIONS: Core stability exercises in addition to conventional treatment significantly decreased pain and improved func-
tion for women with postpartum LPP.
Keywords: Core stability exercises, low back pain, pelvic pain, postpartum lumbopelvic pain
1. Introduction1
Lumbopelvic Pain (LPP) refers to self-reported pain2
in areas of lower back, anterior pelvis, posterior pelvis,3
or any combination of these locations [1,2]. It is a com-4
mon complaint for women after labour, and this is sup-5
ported by a systematic review which found that 25% of6
newly delivered women experienced low back and/or7
pelvic pain [3]. Also, it has been reported by post-8
partum follow-up studies that about 8–20% of women9
∗Corresponding author: Marwa Shafiek Mustafa Saleh, Lecturer
at Department of Basic Science for Physical Therapy, Faculty of
Physical Therapy, Cairo University, 6 October St., Bolaa, Giza,
Egypt. E-mail: Marwa_shafiek2000@yahoo.com.
still have persistent non-specific LPP for 2–3 years af- 10
ter delivery [4]. The presence of LPP is often iden- 11
tified and confirmed by diagrammatic representations 12
of self-reported pain location alone or in combination 13
with clinical tests [4–11], and most LPP is reported in 14
and around the lumbar area, which is responsible for 15
supporting the majority of the upper body weight [12]. 16
Factors associated with LPP occurrence in the post- 17
natal period include maternal age, parity, obesity, 18
smoking, oral contraceptives, previous history of LPP, 19
uncomfortable working conditions, and lack of exer- 20
cise [9,13–16]. Also, non-optimal stability which re- 21
sult from weakening or insufficient motor control of 22
the trunk muscles, is proposed as the most common 23
cause for postpartum LPP [17–19]. 24
ISSN 1053-8127/18/$35.00 c© 2018 – IOS Press and the authors. All rights reserved
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2 M.S.M. Saleh et al. / Effect of core stability exercises on postpartum LPP
Persistent LPP can negatively impact women’s abil-25
ity to perform daily activities and quality of life.26
Among postnatal women it has been shown that LPP27
leads to sleep problems, depression, fatigue, anxiety28
and a general inability to do activities that involve car-29
rying or lifting [20–23]. For instance, Gutke et al. [20]30
found that women suffering from LPP are three times31
more likely to experience symptoms of postnatal de-32
pression compared to those without LPP. In another33
study conducted by Gutke et al. [4], 40 % of women34
with postnatal LPP reported moderate to severe dis-35
ability with pain intensity being the major explanatory36
variable for disability level. They also found that the37
impact of having pelvic girdle pain, combined pain or38
lumbar pain were equivalent in terms of disability, pain39
intensity, health-related quality of life, activity level40
and kinesiophobia.41
Different interventions have been used to reduce42
LPP in general including exercise, acupuncture, drugs,43
therapies using heat/cold, traction, laser, ultrasound,44
short wave and massage [24,25]. An increasingly com-45
mon approach used within the physical therapy man-46
agement of Low Back Pain (LBP) and lower extrem-47
ity pathology is the core stabilization exercises [26],48
which is a form of training that challenges the sta-49
bility of the spine while training muscle activity pat-50
terns and postures that ensure sufficient stability with-51
out unnecessarily overloading tissue [27,28]. Clinical52
trials and experimental studies using these types of ex-53
ercises have shown improved objective and subjective54
outcomes in specific subgroups of patients with LBP,55
such as those with radiologic evidence of instability,56
acute first-episode LBP and pelvic girdle pain [29,30].57
The core as described by Akuthota et al. [31] is58
a muscular box with the abdominals in the front,59
paraspinals and gluteals in the rear, the diaphragm at60
the top, and the pelvic floor and hip girdle muscula-61
ture at the bottom. The muscles and joints of the hip,62
pelvis, and spine are located centrally to maintain sta-63
bility necessary for the limbs to function properly, thus64
providing the proximal stability required for distal mo-65
bility of the kinetic chain [32]. Hence, the main empha-66
sis of core strengthening is focused on muscular sta-67
bilization of abdominal, paraspinal and gluteal muscu-68
lature [33]. Strengthening and neuromuscular reeduca-69
tion of the core musculature is thought to play a sig-70
nificant role in restoring stability to the spinal column71
and in turn minimizing pain associated instability [32],72
which developed partially in response to evidence in-73
dicating specific neuromuscular alterations in the con-74
trol and activation of the back and abdominal muscles75
in the presence of back pain [34–38].76
Although core stability training has become a popu- 77
lar fitness trend that has begun to be applied in rehabil- 78
itation programs [31], up until now the literature was 79
unable to identify any study the effect of core stabil- 80
ity exercises in treating postpartum LPP. Consequently, 81
the purpose of this randomized controlled study was to 82
evaluate the effect of core stability exercises in treating 83
postpartum LPP. 84
2. Methods 85
This pre-test/post-test randomized experimental trial 86
was conducted at the Outpatient Clinic of the Faculty 87
of Physical Therapy at Cairo University, Egypt, from 88
November 2017 to March 2018. The study protocol 89
was explained in detail to each patient before the ini- 90
tial assessment and enrollment in the study. All pa- 91
tients signed an institutionally approved informed con- 92
sent form which was approved by the Ethics Commit- 93
tee of the Faculty of Physical Therapy at Cairo Univer- 94
sity (P.T.REC/012/001882). The study was registered 95
in the Pan African Clinical Trial Registry database (no. 96
PACTR 201802003232225). 97
2.1. Study population 98
Women who suffered from pain in areas of lower 99
back and pelvis were initially screened. After the 100
screening process, women were eligible to participate101
in the study if they had an age ranging from 25– 102
35 years, parity (2–4) times, a body mass index that 103
did not exceed 30 Kg/m2, LPP after at least three 104
months until one year postpartum, and positive test re- 105
sults for two tests: the active straight leg raise test and 106
the posterior pelvic pain provoking test. Women were 107
excluded if they were pregnant, had systemic inflam- 108
matory diseases, prolapsed disc, neuromuscular disor- 109
ders (sciatica), gynaecological disorders (genital pro- 110
lapse), serious cardiovascular disease, diagnosed psy- 111
chiatric disease, recent surgery, fractures, tumors, in- 112
fections or osteoporosis. A diagram of patients’ reten- 113
tion and randomization throughout the study is shown 114
in Fig. 1. The figure shows that 52 patients were ini- 115
tially screened and that after the screening process 34 116
patients were eligible to participate in the study. 117
The women were randomly assigned to the study 118
group (n = 17) or the control group (n = 17) by an 119
independent person who selected numbers from sealed 120
envelopes containing numbers chosen by a random 121
number generator. The randomization was restricted to 122
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M.S.M. Saleh et al. / Effect of core stability exercises on postpartum LPP 3
Fig. 1. Flow chart of study participants.
permuted blocks of different sizes to ensure that equal123
numbers were allocated to each group. The sequences124
assigned to the participants were placed in envelopes125
containing the allocation to each group. An indepen-126
dent person who was blinded to the research protocol127
and not otherwise involved in the trial operated the ran-128
dom assignment.129
Patients in both the study and the control group re-130
ceived the same traditional treatment. This includes in-131
frared irradiation followed by continuous ultrasound132
on the lumbosacral region. The patient was instructed133
to lie prone and her clothes were removed so that the134
skin in the lumbosacral region was exposed. Infrared135
irradiation was applied on the lumbosacral spine for136
15 minutes at a 50–75 cm distance (R 125, 250 watt,137
Philips; 126597: Australia). Then, continuous ultra-138
sound was used with 1.5 W/cm2 intensity and at a139
frequency of 1 MHz over the lumbosacral area, using140
Metron Accusonic Plus (Metron Medical, Australia141
Pty Ltd. Carrum Downs Victoria Australia 3201). The142
duration of ultrasound was estimated for each patient143
using Grey’s formula. The average local exposure time144
was planned to be 1 minute and the effective radiat-145
ing area of the transducer head was 5 cm2. For a pa-146
tient with an area of low back pain of 40 cm2, for ex-147
ample, the required total treatment time was: 1 min ×148
(40 cm2/5 cm2) = 8 minutes. This conventional treat-149
ment was repeated 3 times a week for 6 weeks. Those 150
in the control group received this conventional treat- 151
ment only. 152
The study group additionally received core stability 153
exercises 3 times a week for 6 weeks. Before the pa- 154
tient started the main stability exercise, she performed 155
a warm-up exercise which involved a “Cat-Camel” 156
motion of the spine (spine flexion-extension cycles), 157
stretching exercises for calf, hamstring, quadriceps and 158
lower back for about 5 minutes. After that, the partici- 159
pant was asked to perform the core stability exercises. 160
Each exercise was repeated for 10 repetitions with brief 161
rest periods of 3 sec between repetitions and 1 minute 162
rest between each exercise. It is recommended that 163
the isometric contraction in each repetition be held no 164
longer than 7–8 sec [39]. During each repetition for ev- 165
ery exercise, the patient was asked to contract her ab- 166
dominal muscles and maintain this contraction while 167
maintaining her normal breathing pattern. 168
– Abdominal hollowing: The patient assumed the 169
crock lying position and the therapist stride stand- 170
ing at the level of patient’s waist line with both 171
thumbs placed bilaterally anterior and inferior to 172
the anterior superior iliac spine and the fingers 173
of both hands fanned bilaterally lateral to rectus 174
abdominus muscles. Then, the patient was asked 175
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4 M.S.M. Saleh et al. / Effect of core stability exercises on postpartum LPP
to contract her abdominal muscles and press her176
lumbar region down and hold.177
– Bilateral knee raise: From crock lying position,178
the patient was asked to slowly raise her right leg179
toward her chest until it just passes 90 degrees of180
hip flexion while allowing the knee to flex nor-181
mally and hold the right leg in this position. Then,182
she was asked to lift her left leg in the same way183
so both legs would be elevated. Then, she had to184
return her right leg to the starting position fol-185
lowed by the left leg.186
– Supine extension bridge: The patient was lying on187
her back with knees bend and feet flat on the bed.188
She was asked to slowly raise her pelvis up from189
the bed until the trunk is in line with the thigh190
with maintaining her head, upper back, arms and191
both feet as the point of contact with the plinth192
and hold. Then, she was asked to lower her hips193
slowly to the bed.194
– Straight leg rise from prone: From prone lying po-195
sition, the patient was asked to slowly raise her196
right lower limb toward the ceiling while main-197
taining her knee extended and hold. Then, she was198
asked to return her right leg to the starting posi-199
tion and repeat this exercise alternatively with the200
left lower limb. After this, the patient was asked to201
slowly raise both her right and left lower limb to-202
ward the ceiling while maintaining her knees ex-203
tended and hold, then return them slowly to the204
bed.205
– Alternate arm and leg raise from quadruped posi-206
tion: The patient assumed the prone kneeling po-207
sition and was instructed to keep her body move-208
ments controlled while performing each step of209
exercise. The patient was asked to flex her right210
upper limb and hold, then relax and return to start-211
ing position, and repeat this action on the left up-212
per extremity. Then, the patient was asked to raise213
her right leg backwards off the table no higher214
than her buttocks and hold, then lower her foot215
back to the table and relax, and repeat this action216
to the left leg. After this, the patient was asked to217
raise the right arm and left leg (opposite upper and218
lower limbs) and hold then relax, and repeat this219
action on the opposite arm and leg.220
– Prone abdominal body bridge: From prone lying221
position, the patient was asked to slowly raise her222
body up from the treatment table allowing the el-223
bows and feet to be the point of contact with the224
treatment table, then relax and return to the start-225
ing position.226
The outcome measures were carried out for each pa- 227
tient individually before and after 6 weeks of treatment 228
by the outcome assessor who was not masked during 229
the study. The main outcome variable was pressure 230
pain thresholds (PPT) using a pressure algometer. The 231
pressure algometer has been found to be non-invasive, 232
efficient and reliable in the exploration of physio- 233
pathological mechanisms involved in muscle pain syn- 234
dromes [40]. In this study we used a pressure algome- 235
ter (12-0303 Push-Pull Force Gauge, Fabrication En- 236
terprises, Inc., USA) with a probe size of 1.0 cm2. 237
Prior to administration on the participants, the device 238
was calibrated in the laboratory with a 30 KG weight. 239
The PPT was measured in kilograms. The pressure was 240
applied on the same marked area over the lumbar re- 241
gion, and the pressure was incrementally increased at 242
a rate of 250 gram.The patient was instructed to lie 243
prone with both forearms over the sides and her clothes 244
were removed so that the skin in the region of the lum- 245
bosacral spine and PSIS bilaterally was exposed. The 246
assessor measured the trigger points at 3 cm lateral to 247
the spinous processes (L1-S5). This measurement site 248
was marked by using a grease pencil to make sure that 249
the same point is measured during the procedure. Fur- 250
thermore, the sites were photographed after its mark- 251
ing to improve the reliability of PPT measurements at 252
the post treatment assessment. During PPT measure- 253
ment, the assessor positioned the algometer’s circular 254
probe perpendicular to the skin and pressed, and the 255
participant was asked to say “stop” when the sensation 256
of pressure or discomfort became a clear sensation of 257
pain. Four consecutive PPT measures were performed 258
at each location with 30 sec of rest between measure- 259
ments. The first PPT measure was discarded and the 260
mean of the subsequent 3 PPT for each location was 261
taken, and then the average mean of PPT for all trig- 262
ger points for each patient was calculated and used for 263
further analysis. 264
Other outcome measures used to compare the treat- 265
ment effectiveness between the study and control 266
groups included severity of pain and disability. Sever- 267
ity of pain was evaluated by the Visual Analogue Scale 268
(VAS). Each patient was asked to mark and score on a 269
line at the point that represents her intensity of pain on 270
a 100 millimeter scale, in which 0 represents no pain 271
and 100 represents maximal pain intensity [41]. 272
Disability was measured using the Oswestry Dis- 273
ability Index (ODI). ODI consists of 10 sections that 274
evaluate pain and domains of daily life that might be 275
disrupted by low back pain, including: personal care, 276
lifting, walking, sitting, standing, sleeping, sexual ac- 277
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Table 1
Baseline participant demographics
Study group Control group
X̄ ± SD X̄ ± SD MD t-value p-value
Age (years) 29.88 ± 2.97 29.52 ± 2.57 0.36 0.37 0.71∗
BMI (kg/m2) 26.47 ± 2.06 26.8 ± 2.13 −0.33 −0.46 0.64∗
Number of deliveries 2.88 ± 0.78 2.94 ± 0.74 −0.06 −0.22 0.82∗
X̄ , mean; SD, standard deviation; MD, mean difference; p-value, level of significance; ∗non significant.
Table 2
Mean and standard deviations of PPT, pain intensity and disability
Pre treatment Post treatment
Study group Control group Study group Control group Repeated measures Repeated measures
(study) (control)
X̄ ± SD X̄ ± SD P value X̄ ± SD X̄ ± SD P value P value P value
PPT (kg/cm2) 3.19 ± 0.38 3.12 ± 0.36 0.62∗ 4.51 ± 0.3 3.64 ± 0.41 0.001∗∗ 0.001∗∗ 0.001∗∗
VAS 61.76 ± 12.86 59.41 ± 11.44 0.57∗ 18.82 ± 8.57 32.35 ± 12.51 0.001∗∗ 0.001∗∗ 0.001∗∗
ODI 54.35 ± 11.51 54 ± 11.29 0.92∗ 21.88 ± 7.54 29.82 ± 9 0.009∗∗ 0.001∗∗ 0.001∗∗
X̄ , mean; SD, standard deviation; p-value, level of significance; ∗Non significant; ∗∗Significant; PPT: Pain Pressure Threshold; VAS: Visual
Analogue Scale; ODI: Oswestry DisabilityIndex.
tivity, social activity and traveling. Each section was278
scored on a 0–5 scale, in which 5 represented the great-279
est disability. The index was calculated by dividing the280
summed score by the total possible score, which was281
then multiplied by 100 and expressed as a percentage.282
Thus, for every question not answered, the denomina-283
tor was reduced by 5. If a patient marked more than one284
statement in a question, the highest scoring statement285
was recorded as a true indication of disability. Scores286
are reported on a 0–100% scale with 100% represent-287
ing severe disability [42].288
2.2. Sample size determination289
On the basis of a pilot study, the primary clini-290
cal outcome of the current study was that PPT ob-291
tained a power of 0.9 with a significant level of 0.05292
with a large effect size of 1.9; total sample size es-293
timation would be 14 participants per group using294
G*power 3.1 software (Institut für Experimentelle Psy-295
chologie: HeinrichHeine-Universität niversitätsstraße,296
Düsseldorf, Germany). To account for dropout rates,297
the sample size was increased by 20%, to be 17 per298
group.299
2.3. Data analysis300
Descriptive analyses, including mean and standard301
deviation, were performed for all variables. T-test was302
conducted for comparison of subject characteristics be-303
tween both groups. Normal distribution of data was304
checked using the Shapiro-Wilk test for all variables.305
Levene’s test for homogeneity of variances was con- 306
ducted to test the homogeneity between groups. Mixed 307
MANOVA was conducted to compare the mean values 308
of PPT, VAS and ODI between the study and control 309
groups, as well as between group comparison and be- 310
tween pre- and post-treatment in each group as within 311
group comparison. Post-hoc tests using the Bonfer- 312
roni correction were carried out for subsequent multi- 313
ple comparison. The level of significance for all sta- 314
tistical tests was set at p < 0.05. All statistical anal- 315
ysis was conducted through the statistical package for 316
social studies (SPSS) version 19 for Windows (IBM 317
SPSS, Chicago, IL, USA). 318
3. Results 319
3.1. Base line participant characteristics 320
The clinical and demographic features of the pa- 321
tients are presented in Table 1. 322
3.2. Between group analysis 323
Results are summarized and presented as mean (SD) 324
in Table 2. No statistically significant differences were 325
observed between the two groups in any variables at 326
baseline, while after 6 weeks of treatment there was a 327
significant increase in the PPT and significant decrease 328
in VAS and ODI of the study group compared with that 329
of control group (p < 0.01). 330
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6 M.S.M. Saleh et al. / Effect of core stability exercises on postpartum LPP
4. Discussion331
This study demonstrates that the group who received332
core stability exercises in addition to traditional treat-333
ment in form of infrared radiation and continuous ul-334
trasound showed more improvement than the control335
group in pain and functional disability based on the in-336
crease in PPT and decrease in pain intensity and ODI.337
The core stability group’s statistically significant in-338
crease in the PPT are in accordance with the findings339
of Cho et al. [43] who conducted a study to evaluate340
the effects of the core exercise program on pain and341
active range of motion in patients with chronic LBP,342
and reported that the core group showed significantly343
increased PPT in the quadratus lumborum. Further-344
more, this result corresponds to the result of a study by345
Senthil [44], who confirmed a statistically significant346
increase in PPT after applying segmental stabilization347
exercise in chronic LBP patients. In the same line,348
Paungmali et al. [45] reported that the PPT increased349
by approximately 7.6% after lumbopelvic stabilization350
training, and they concluded that lumbopelvic stabi-351
lization training may be considered as part of the man-352
agement programs for treatment of chronic LBP.353
In the case of chronic pain conditions, such as354
chronic LPP, the central neuroplastic changes play an355
important role in the processing of abnormal pain.356
These changes are caused by continued stimulation357
rather than by inflammation or damage to peripheral358
structures. Therefore, patients experience increased359
sensitivity to pressure and to pain stimuli of a normal360
degree [46]. According to the biomechanical model361
theory, weakened muscles cause mechanical irritation362
in the lumbar spine, thereby causing pain by stimulat-363
ing pain-sensitivestructures [47]. Such continued stim-364
ulation serves as an initial cause of central sensitization365
and chronic pain [48]. It has been reported by Kumar366
et al. [49] that core stability exercises have the ability367
to adequately strengthen all trunk muscles responsible368
for maintaining a strong and stable spine without ex-369
ceeding cautious injury thresholds for compressive and370
shear loading. Thus, core stabilization exercises help371
activate the deep abdominal muscles, restore the func-372
tion of weakened muscles and augment the ability to373
support and control the spine and pelvis, which help to374
alleviate the mechanical irritation and pain. This might375
explain the significant increase in the pain threshold376
and reduced pain intensity in the study group in com-377
parison to the control group in the current study.378
The reduction of pain intensity in the study group,379
which received core stability exercise, is in agreement380
with the findings of Javadian et al. [50] who demon- 381
strated that an 8-week stabilization exercise program 382
(involving abdominal bracing and abdominal hollow- 383
ing exercises) plus routine exercise was more effec- 384
tive than routine exercise alone in reducing pain and 385
disability in a similar subgroup of LBP patients, both 386
post-intervention and at a 3 month follow-up. This 387
is similar to the results by Goldby et al. [51] which 388
showed pain reduction in chronic LBP patients after 389
10 weeks of specific spinal stabilization, as well as 390
those of Koumantakis et al. [52], who showed the con- 391
tinuation of significant pain reduction in patients with 392
LBP 3 months after application of stabilization en- 393
hanced exercise. The result of the current study are also 394
in line with the study by Wang et al. [53], who stated 395
that compared to general exercise, core stability exer- 396
cise is more effective in decreasing pain and may im- 397
prove physical function in patients with chronic LBP. 398
On the contrary, the findings of the current study 399
concerning the reduction of pain intensity in the core 400
stability group are in contrast with those of other stud- 401
ies conducted by Shamsi et al. [54] and Cairns et 402
al. [55]. They concluded that core stability exercise 403
is not more effective than general exercise for reduc- 404
ing pain in chronic non-specific LBP patients, and that 405
there was no additional benefit of adding spinal sta- 406
bilization exercises to a conventional physiotherapy 407
package for patients with recurrent LBP. This contra- 408
diction may be attributed to difference in the conven- 409
tional treatment modalities for the control group be- 410
tween their studies and the current study, as in their 411
studies the control group received a general exercise 412
which may lead to a generalized increased activity 413
rather than the core stability exercise. 414
The significant reduction in the pain intensity in the 415
core stability group in comparison to the control group, 416
might be explained by the effect of core stability ex- 417
ercise in increasing the tissue blood flow to the af- 418
fected area which may help to relief the pain by sup- 419
plying more oxygen and nutrients to the painful area 420
as well as removing waste products and irritant sub- 421
stances from the sensitive tissues. This explanation is 422
in line with the study by Paungmali et al. [56], who in- 423
vestigated the effect of lumbopelvic core stabilization 424
training in improvements of tissue blood flow and lum- 425
bopelvic stability in patients with chronic non-specific 426
LBP. They reported that after core stability training 427
there are significant improvements in the tissue blood 428
flow and lumbopelvic stability levels among patients 429
with chronic non-specific LBP. 430
Increasing the functional performance of patients 431
with LPP is a desirable and tangible outcome to re- 432
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M.S.M. Saleh et al. / Effect of core stability exercises on postpartum LPP 7
searchers but most importantly to patients. Concern-433
ing the significant improvement in LPP intensity and434
functional disability in the core stability group com-435
pared with the control group in the current study is in436
agreement with the findings of França et al. [57] who437
reported that segmental stabilization exercises effec-438
tively reduce pain and functional disability in individu-439
als with chronic LBP. Furthermore, functional disabil-440
ity improvement was in line with the study of Stuge441
et al. [30] who found that specific stabilizing exercises442
were considerably more effective in improving func-443
tional status and improving health related quality of444
life as compared to an intervention without specific sta-445
bilization exercises.446
The current study has some limitations, however,447
each of which point toward directions of future study.448
The primary limitation was the lack of blinding of the449
physiotherapist who provided interventions, due to the450
type of intervention which need the direct communi-451
cation between the physiotherapist and the patients.452
In addition, the initial selection of the patients was453
represented as a convenient sample rather than a ran-454
dom sample of the whole population. Furthermore, the455
study considered only the immediate effects of core456
stability exercise on pain intensity and functional dis-457
abilities among postpartum LPP patients and did not458
reflect the long term effects. Despite the limitations,459
the current randomized controlled study indicates that460
core stability exercises may be appropriate treatment461
for postpartum LPP by improving the pain threshold462
and increasing the pain intensity and functional perfor-463
mance.464
5. Conclusion465
The results of the present study show that core sta-466
bility exercise in addition to infrared radiation and con-467
tinuous ultrasound have positive effects on pain thresh-468
old, pain intensity and disability. These observed ef-469
fects should be of value to clinicians and health profes-470
sionals involved in the treatment of postpartum LPP.471
Acknowledgments472
The authors would like to thank all participants for473
their collaboration in this study.474
Conflict of interest475
None to report.476
References 477
[1] Vøllestad NK, Stuge B. Prognostic factors for recovery from 478
postpartum pelvic girdle pain. Eur Spine J 2009; 18: 718–26. 479
[2] Mens JM, Huis YH, Pool-Goudzwaard A. Severity of signs 480
and symptoms in lumbopelvic pain during pregnancy. Man 481
Ther 2012; 17: 175–9. 482
[3] Wu H, Meijer G, Uegaki K, Mens M, van Dieen H, Wuisman 483
I, Ostgaard C. Pregnancy-related pelvic girdle pain (PPP), I: 484
Terminology, clinical presentation, and prevalence. Eur Spine 485
J 2004; 13(7): 575–589. 486
[4] Gutke A, Lundberg M, Ostgaard C, Oberg B. Impact of post- 487
partum lumbopelvic pain on disability, pain intensity, health- 488
related quality of life, activity level, kinesiophobia, and de- 489
pressive symptoms. Eur Spine J 2011; 20(3): 440–448. 490
[5] Nilsson-Wikmar L, Pilo C, Pahlbäck M, Harms-Ringdahl 491
K. Perceived pain and self-estimated activity limitations in 492
women with back pain post-partum. Physiother Res Int 2003; 493
8: 23–35. 494
[6] Nilsson-Wikmar L, Holm K, Oijerstedt R, Harms-Ringdahl 495
K. Effect of three different physical therapy treatments on 496
pain and activity in pregnant women with pelvic girdle pain: 497
a randomised clinical trial with 3, 6, and 12 months follow-up 498
postpartum. Spine 2005; 30: 850–6. 499
[7] Gutke A, Kjellby-Wendt G, Öberg B. The inter-rater relia- 500
bility of a standardised classification system for pregnancy- 501
related lumbopelvic pain. Man Ther 2010; 15: 13–8. 502
[8] Robinson HS, Mengshoel AM, Veierød MB, Vøllestad N. 503
Pelvic girdle pain: potential risk factors in pregnancy in rela- 504
tionto disability and pain intensity three months postpartum. 505
Man Ther 2010; 15: 522–8. 506
[9] Malmqvist S, Kjaermann I, Andersen K, Økland I, Brønnick 507
K, Larsen JP. Prevalence of low back and pelvic pain during 508
pregnancy in a Norwegian population. J Manipulative Physiol 509
Ther 2012; 35: 272–8. 510
[10] Olsson CB, Nilsson-Wikmar L, Grooten WJ. Determinants 511
for lumbopelvic pain 6 months postpartum. Disabil Rehabil 512
2012; 34: 416–22. 513
[11] Robinson HS, Vøllestad NK, Veierød MB. Clinical course of 514
pelvic girdle pain postpartum-impact of clinical findings in 515
late pregnancy. Man Ther 2014; 19: 190–6. 516
[12] Walker J. Back pain: pathogenesis, diagnosis and manage- 517
ment. Nurs Stand 2012; 27: 49–56. 518
[13] Kumle M, Weiderpass E, Alsaker E, Lund E. Use of hor- 519
monal contraceptives and occurrence of pregnancy-related 520
pelvic pain: a prospective cohort study in Norway. BMC Preg- 521
nancy Childbirth 2004; 4: 11. 522
[14] Wang SM, Dezinno P, Maranets I, Berman MR, Caldwell- 523
Andrews AA, Kain ZN. Low back pain during pregnancy: 524
prevalence, risk factors, and outcomes. Obstet Gynecol 2004; 525
104: 65–70. 526
[15] Bjelland EK, Eskild A, Johansen R, Eberhard-Gran M. Pelvic 527
girdle pain in pregnancy: the impact of parity. Am J Obstet 528
Gynecol 2010; 203: 146. 529
[16] Al-Sayegh NA, Salem M, Dashti L, Al-Sharrah S, Kalakh 530
S, Al-Rashidi R. Pregnancy-related lumbopelvic pain: preva- 531
lence, risk factors, and profile in Kuwait. Pain Med 2012; 13: 532
1081–7. 533
[17] O’Sullivan B, Beales J. Diagnosis and classification of pelvic 534
girdle pain disorders – Part 1: A mechanism based approach 535
within a biopsychosocial framework. Man Ther 2007; 12: 86– 536
97. 537
[18] Vleeming A, Albert B, Östgaard C, et al. European guide- 538
lines for the diagnosis and treatment of pelvic girdle pain. Eur539
un
co
rre
cte
d p
roo
f v
ers
ion
Galley Proof 21/09/2018; 8:37 File: bmr–1-bmr181259.tex; BOKCTP/xjm p. 8
8 M.S.M. Saleh et al. / Effect of core stability exercises on postpartum LPP
Spine J 2008; 17(6): 794–819.540
[19] Vermani E, Mittal R, Weeks A. Pelvic girdle pain and low541
back pain in pregnancy: a review. Pain Pract 2009; 10(1): 60–542
71.543
[20] Gutke A, Josefsson A, Oberg B. Pelvic girdle pain and lum-544
bar pain in relation to postpartum depressive symptoms. Spine545
2007; 32: 1430–6.546
[21] Ko YL, Yang CL, Chiang L. Effects of postpartum exercise547
program on fatigue and depression during “doing-the-month”548
period. J Nurs Res 2008; 16: 177–86.549
[22] Cramp AG, Bray SR. Postnatal women’s feeling state re-550
sponses to exercise with and without baby. Matern Child551
Health J 2010; 14: 343–9.552
[23] Ko Y, Lee H. Randomised controlled trial of the effective-553
ness of using back massage to improve sleep quality among554
Taiwanese insomnia postpartum women. Midwifery 2014; 30:555
60–4.556
[24] Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-557
Moffett J, Kovacs F, et al. Chapter 4 European guidelines for558
the management of chronic nonspecific low back pain. Eur559
Spine J 2006; 15(Suppl 2): 192–300.560
[25] Perry M. Low back pain: tackling a common problem. Pract561
Nurs 2013; 24: 356–8.562
[26] Liddle SD, Baxter GD, Gracey JH. Exercise and Chronic low563
back pain: what works? Pain 2004; 107(1): 176–190.564
[27] Akuthota V, Nadler SF. Core strengthening. Arch Phys Med565
Rehabil 2004; 85(1): 86–92.566
[28] Kavcic N, Grenier S, McGill SM. Quantifying tissue loads567
and spine stability while performing commonly prescribed568
low back stabilization exercises. Spine 2004; 29(20): 2319–569
2329.570
[29] Hides JA, Jull GA, Richardson CA. Long-term effects of571
specific stabilizing exercises for first-episode low back pain.572
Spine 2001; 26: E243–8.573
[30] Stuge B, Laerum E, Kirkesola G, Vollestad N. The efficacy of574
a treatment program focusing on specific stabilizing exercises575
for pelvic girdle pain after pregnancy. Spine 2004; 29(4): 351.576
[31] Akuthota V, Ferreiro A, Moore T, Fredericson M. Core Sta-577
bility Exercise Principles. Curr Sports Med Rep 2008; 7: 39–578
44.579
[32] Kibler WB, Press J, Sciascia A. The role of core stability in580
athletic function. Sports Med 2006; 36: 189–198.581
[33] Nadler SF, Malanga GA, Bartoli LA, Feinberg JH, Prybicien582
M, DePrince M. Hip muscle imbalance and low back pain in583
athletes: Influence of core strengthening. Medicine & Science584
in Sports & Exercise 2002; 34(1): 9–16.585
[34] Hides JA, Richardson CA, Jull GA. Multifidus muscle recov-586
ery is not automatic after resolution of acute, first-episode low587
back pain. Spine 1996; 21: 2763–9.588
[35] Hodges PW, Richardson CA. Inefficient muscular stabiliza-589
tion of the lumbar spine associated with low back pain. A mo-590
tor control evaluation of transverses abdominis. Spine (Phila591
Pa 1976) 1996; 21: 2640–2650.592
[36] O’Sullivan PB, Twomey LT, Allison GT. Evaluation of spe-593
cific stabilizing exercise in the treatment of chronic low back594
pain with radiologic diagnosis of spondylolysis or spondy-595
lolisthesis. Spine 1997; 22: 2959–67.596
[37] McGill S. Low Back Disorders: Evidence-Based Prevention597
and Rehabilitation. Champaign: Human Kinetics; 2002.598
[38] Moseley GL, Nicholas MK, Hodges PW. Pain differs from599
non-painful attention-demanding or stressful tasks in its effect600
on postural control patterns of trunk muscles. Exp Brain Res601
2004; 156: 64–71.602
[39] McGill S. Low back disorders: evidence-based prevention and 603
rehabilitation. 2nd edition. Champaign, IL: Human Kinetics;604
2007.605
[40] Imamura M, Alfieri F, Filippo T, Battistella L. Pressure pain606
thresholds in patients with chronic nonspecific low back pain.607
J Back Musculoskelet Rehabil 2016; 29(2): 327–336.608
[41] Grotle M, Brox J, Vollestad N. Concurrent comparison of re-609
sponsiveness in pain and functional status measurements used610
for patients with low back pain (Phila Pa 1976) 2004; 29(21):611
492–501.612
[42] Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G,613
Shekelle P, Denniger TR, Godges JJ. Low Back Pain: Clinical614
Practice Guidelines Linked to the International Classification615
of Functioning, Disability, and Health from the Orthopaedic616
Section of the American Physical Therapy Association. J Or-617
thop Sports Phys Ther 2012; 42(4): 1–57.618
[43] Cho HY, Kim E, Kim J. Effects of the core Exercise Program619
on Pain and Active Range of Motion in Patients with Chronic620
Low Back Pain. J Phys Ther Sci 2014; 26: 1237–1240.621
[44] Senthil P. Efficacy of segmental stabilization exercise for lum-622
bar segmental instability in patients with mechanical low back623
pain: A randomized placebo controlled crossover study. N624
Am J Med Sci 2011; 3(10): 456–461.625
[45] Paungmali A, Joseph LH, Sitilertpisan P, Pirunsan U,626
Uthaikhup S. Lumbopelvic Core Stabilization Exercise and627
Pain Modulation Among Individuals with Chronic Nonspe-628
cific Low Back Pain. Pain Practice 2017; 17(8): 1008–1014.629
[46] Mense S. Biochemical pathogenesis of myofascial pain. J630
Musculoskeletal Pain 1996; 4: 145–162.631
[47] Panjabi MM. The stabilizing system of the spine. Part I., dys-632
function, adaptation, and enhancement. J Spinal Disord 1992;633
5: 383–389; discussion 397.634
[48] Woolf CJ. Central sensitization: implications for the diagnosis635
and treatment of pain. Pain 2011; 152(suppl): S2–S15.636
[49] Kumar C, Rao S, Thakur P. Effectiveness of core stability ex-637
ercise program on abdominal and back strength in school go-638
ing children: A randomized controlled trial. IJND 2015; 5(7):639
7–13.640
[50] Javadian Y, Behtash H, Akbari M, Taghipour-Darzi M, Zeka-641
vat H. The effects of stabilization exercises on pain and dis-642
ability of patients with lumbar segmental instability. J Back643
Musculoskelet Rehabil 2012; 25: 149–155.644
[51] Goldby LJ, Moore AP, Doubst J, Trew ME. A randomized645
controlled trial investigating the efficacy of musculoskeletal646
physiotherapyon chronic low back disorder. Spine 2006; 31:647
1083–1093.648
[52] Koumantakis GA, Watson PJ, Oldham JA. Trunk muscle sta-649
bilization training plus general exercise versus general exer-650
cise only: Randomized con-trolled trial of patients with recur-651
rent low back pain. Phys Ther 2005; 85: 209–25.652
[53] Wang XQ, Zheng JJ, Yu ZW, Bi X, Lou SJ, Liu J, Cai B,653
Hua YH, Wu M, Wei ML, Shen HM, Chen Y, Pan YJ, Xu654
GH, Chen PJ. A meta-analysis of core stability exercise versus655
general exercise for chronic low back pain. PLoS One 2012;656
7(12): e52082.657
[54] Shamsi MB, Rezaei M, Zamanlou M, Sadeghi M, Pourahmadi658
MR. Does core stability exercise improve lumbopelvic stabil-659
ity (through endurance tests) more than general exercise in660
chronic low back pain? A quasi-randomized controlled trial.661
Physiother Theory Pract 2016; 32(3): 171–178.662
[55] Cairns C, Foster E, Wright C. Randomized Controlled Trial663
of Specific Spinal Stabilization Exercises and Conventional664
Physiotherapy for Recurrent Low Back Pain. Spine 2006;665
31(19): 60–681.666
[56] Paungmali A, Leonard H, Sitilertpisan P, Ubon P, Sureeporn667
un
co
rre
cte
d p
roo
f v
ers
ion
Galley Proof 21/09/2018; 8:37 File: bmr–1-bmr181259.tex; BOKCTP/xjm p. 9
M.S.M. Saleh et al. / Effect of core stability exercises on postpartum LPP 9
U. Improvements in tissue blood flow and lumbopelvic sta- 668
bility after lumbopelvic core stabilization training in patients 669
with chronic non-specific low back pain. J Phys Ther Sci 670
2016; 28: 635–640. 671
[57] França FR, Burke TN, Hanada ES, Marques AP. Segmental672
stabilization and muscular strengthening in chronic low back673
pain: a comparative study. Clinics 2010; 65(10): 1013–10177.674
un
co
rre
cte
d p
roo
f v
ers
ion