SPINE Volume 42, Number 15, pp E876–E882

ß 2017 Wolters Kluwer Health, Inc. All rights reserved.

RANDOMIZED TRIAL

Effects of Low-Load Motor Control Exercises

and a High-Load Lifting Exercise on Lumbar
Multifidus Thickness
A Randomized Controlled Trial

Lars Berglund, PhD, RPT,,y,{ Björn Aasa, MSc, RPT,y,z

Peter Michaelson, PhD, RPT,§ and Ulrika Aasa, PhD, RPT ,{

with the large side in both intervention groups, without

Study Design. Randomized controlled trial.
influence of pain at baseline, or change in pain intensity.
Objective. The aim of this study was to compare the effects of
Conclusion. At baseline, there was a difference in thickness of
low-load motor control (LMC) exercises and a high-load lifting
the LM muscles between sides. It seems that exercises focusing
(HLL) exercise, on lumbar multifidus (LM) thickness on either
on spinal alignment may increase the thickness of the LM
side of the spine and whether the effects were affected by pain
muscles on the small side, irrespective of exercise load. The
intensity or change in pain intensity.
increase in LM thickness does not appear to be mediated by
Summary of Background Data. There is evidence that
either current pain intensity or the magnitude of change in pain
patients with low back pain (LBP) may have a decreased size of
intensity.
the LM muscles with an asymmetry between sides in the lower
Key words: asymmetry, deadlift, exercise, low back pain,
back. It has also been shown that LMC training can affect this
morphology, motor control, movement control, pain intensity,
asymmetry. It is, however, not known whether a high-load physical therapy, resistance training, stabilization training,
exercise has the same effect. ultrasonography multifidus.
Methods. Sixty-five participants diagnosed with nociceptive Level of Evidence: 2
mechanical LBP were included and randomized into LMC Spine 2017;42:E876–E882
exercises or a HLL exercise, the deadlift. The LM thickness was
measured using rehabilitative ultrasound imaging (RUSI), at

baseline and after a 2-month training period.
Results. There were no differences between interventions
regarding effect on LM muscle thickness. However, the analysis
showed a significant effect for asymmetry. The thickness of the
LM muscle on the small side increased significantly compared
From the Department of Community Medicine and Rehabilitation, Umeå
University, Sweden; yDepartment of Surgical and Perioperative Sciences,
Umeå University, Sweden; zNorrlandskliniken Health Care Centre, Umeå,
Sweden; §Division of Health and Rehabilitation, Department of Health
Science, Luleå University of Technology, Sweden; and {Umeå School of
Sport Sciences, Umeå University, Sweden.
Acknowledgment date: August 17, 2015. First revision date: February 12,
2016. Second revision date: June 10, 2016. Third revision date: August 19,
2016. Fourth revision date: October 21, 2016. Acceptance date: November
2, 2016.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
Visare Norr and Norrbottens County Council grant funds were received in
support of this work.
Relevant financial activities outside the submitted work: employment.
Address correspondence and reprint requests to Lars Berglund, PhD, RPT,
Department of Community Medicine and Rehabilitation, Umeå University,
SE-901 87 Umeå, Sweden; E-mail: lars.berglund@umu.se
DOI: 10.1097/BRS.0000000000001989
E876 www.spinejournal.com
T
he lumbar multifidus (LM) muscles are important for
controlling the magnitude of motions in the lumbar
spine.1 It has been shown that patients with low back
pain (LBP) might have impairments related to LM muscle
size.2–4 More specifically, imaging studies have reported
smaller LM muscle cross-sectional area and muscle thick-
ness2,4–7 and more fatty infiltration6,8,9 in patients with
LBP. Also, it seems that patients with LBP may display
an asymmetry of LM size between the left and right sides4,10
and that a greater ratio of asymmetry may be associated
with higher pain intensity levels.11 Further, it seems import-
ant to investigate which exercises can affect size and sym-
metry between sides since it has been shown that exercises
targeting the LM muscles can reduce recurrence of LBP.12
However, there are also studies that indicate that asymmetry
between sides is frequent in both symptomatic and asymp-
tomatic populations.13
Previously, only two exercise approaches have aimed to
restore size and symmetry of LM muscles. First, low-load
motor control (LMC) exercises,14 which have been shown to
reduce pain intensity with concomitant improvements
in LM size and symmetry in patients with LBP.10 Second,
high-load resistance training of the back extensors15 have
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 RANDOMIZED TRIAL Exercise and Lumbar Multifidus Thickness  Berglund et al

been evaluated in three studies on patients with LBP
where in Willemink et al,16 patients showed a reduction
in disability, without a change in LM size, while Steele
et al17 showed reduced disability and pain intensity, and
Danneels et al18 showed an increase of the size of the LM
muscles. Notably, Steele et al17 did not evaluate LM size
and Danneels et al18 did not evaluate pain intensity or
disability. In conclusion, both exercise approaches seem
effective in accordance with present evidence stating that
most exercise interventions have positive and clinically
relevant effects on pain and disability.19 However, there
are no studies comparing low-load exercises to high-load
exercises regarding their effects on size and/or symmetry
of the LM muscles and no studies that have evaluated
the influence of perceived pain intensity on LM
thickness change.
A recent study from our research group showed that in 70
patients with nociceptive mechanical LBP, both LMC exer-
cises and a high-load lifting (HLL) exercise, the barbell
deadlift, in combination with education, lead to clinically
relevant improvements in pain intensity for a majority of the
participants in the study.20 Still, neither the thickness of the
LM muscles, nor the effects of LMC and HLL on LM
thickness was reported. Therefore, the primary aim of this
study was, to investigate the LM thickness and compare
the effects of LMC exercises and a HLL exercise, on LM
thickness among patients with nociceptive mechanical
LBP. Also, a secondary aim was to investigate whether
changes in LM thickness was affected by baseline or change
in pain intensity.
MATERIALS AND METHODS
Study Design
This study is part of a larger data collection evaluating
the effects of LMC exercises and an HLL exercise
(NCT01061632).20 Here, we investigated the effects on
percentage change [(follow-up  baseline/baseline)  100]
in thickness of the LM muscle at the fifth lumbar vertebra
at the small and large sides. The study protocol was
approved by The Regional Ethical Review Board in Umeå
(No. 09–200M).
Participants
Consecutive individuals seeking care for LBP with a
duration of more than 3 months at two occupational health
care centers, and classified as having nociceptive mechanical
LBP21 were screened for eligibility (n ¼ 85).20 The eligibility
screening controlled for inclusion and exclusion criteria
such as red (i.e., pathological processes) and yellow flags
(i.e., pain and pain behavior secondary to a dominance of
psycho-social factors),22 and assured that the dominant
underlying pain pattern was of nociceptive mechanical
character.21 Participants who agreed to participate in reha-
bilitative ultrasound imaging (RUSI) of LM thickness were
included. Detailed description of the selection process has
been presented earlier.20 Baseline characteristics of the
participants are presented in Table 1.
Procedure
After the selection process, participants answered a
questionnaire and participated in RUSI measurements.
Thereafter, the randomization procedure was performed
by an investigator who was blinded to the characteristics
of the participants. Participants were stratified by means
of age and sex, and randomly allocated to intervention
groups by a computer generated procedure.20 A second
investigator thereafter contacted each participant giv-
ing times for first appointment. The physical therapist
(PT) performing the RUSI measurements, after the inter-
vention period, was blinded to baseline data, but not
group allocation.

TABLE 1. Baseline Values of Age, BMI, VAS 7 Days at Baseline and Change in VAS 7 Days from
Baseline to Follow-Up, Displayed as Mean and Standard Deviation
Age BMI VAS Baseline VAS Change
LMC n ¼ 33 43.3 (10.3) 25.0 (3.0) 48.4 (27.0) 18.5 (26.7) n ¼ 31
HLL n ¼ 32 42.3 (9.8) 25.4 (3.8) 41.3 (23.8) 19.0 (25.5) n ¼ 29
P 0.67 0.57 0.27 0.95
Men
All n ¼ 28 45.6 (9.2) 25.1 (3.3) 38.8 (22.8) 14.1 (20.8) n ¼ 27
LMC n ¼ 13 48.0 (7.3) 25.0 (3.0) 39.8 (24.2) 10.5 (19.7) n ¼ 12
HLL n ¼ 15 43.6 (10.4) 25.1 (3.6) 37.9 (22.4) 17.1 (21.9) n ¼ 15
P 0.21 0.97 0.83 0.43
Women
All n ¼ 37 40.6 (10.1) 25.3 (3.6) 49.6 (26.8) 22.5 (29.2) n ¼ 33
LMC n ¼ 20 40.3 (10.9) 24.9 (3.1) 54.0 (27.8) 23.6 (29.7) n ¼ 19
HLL n ¼ 17 41.1 (9.4) 25.8 (4.1) 44.4 (25.4) 21.0 (29.6) n ¼ 14
P 0.82 0.48 0.28 0.80

P values for independent-samples t test.
BMI indicates body mass index; HLL, high-load lifting intervention group; LMC, low-load motor control intervention group; VAS, visual analogue scale.

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 RANDOMIZED TRIAL
Interventions
The interventions were carried out with a maximum of 12
sessions over 2-months provided by senior PTs that have used
motor control exercises and/or the deadlift exercise in their
clinical practice for at least 5 years. Education regarding basic
aspects of pain and tissue mechanisms with emphasis on how
non-ideal movement and alignment strategies could contrib-
ute to the participants’ LBP was also provided for the partici-
pants within each intervention. A detailed description of both
interventions has been provided earlier.20
High-Load Lifting Exercise
The deadlift exercise was the only exercise in the HLL
intervention. During training, the PT emphasized instruc-
tions to ensure that the participants maintained a neutral
alignment of the low back as well as activation of the
stabilizing muscle of the lumbar spine while lifting and
lowering the barbell from the floor. The initial sessions
focused on establishing a proper technique with relatively
low loads (10–20 kg) at three to five sets of 10 repetitions.
Thereafter the progression started with the goal of increas-
ing the total number of kilograms lifted compared with the
previous session in order to stimulate hypertrophy and
maximal strength. This was done by increasing number
of sets to five to eight per session while repetitions were
reduced to three to five per set with increased weight on the
bar. The exact progression was controlled by the PT super-
vising the training in communication with each participant.
Low-Load Motor Control Exercises
The LMC intervention was performed using exercises with-
out external resistance. The exercises were tailored to the
participants’ movement impairments and aberrant muscle
activation patterns.22 Static and dynamic exercises focused
on encouraging movement patterns relieving stress from
their area of pain and improving control and timing of
the magnitude of movements in adjacent areas to the low
back. Specific training of muscle activation of local stabil-
izers of the trunk was employed throughout the intervention
as an integral part of all aspects of the movement behavior
retraining. The strategy for progressing the training was to
increase the difficulty of exercises from a coordinative
standpoint where training began at a basic level where
the exercises targeted the participants’ ability to find and
maintain their lumbar neutral position while performing
movements with arms or legs. Thereafter, the training was
progressed to consist of exercises including dynamic move-
ments of the spine in activities the participants had reported
difficulty in performing.
Measurements
Questionnaire
Information about age, sex, height, and weight was col-
lected at baseline. Pain intensity during the last 7 days
(100 mm visual analogue scale [VAS 7 days])23 was
measured at baseline and at follow-up.
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Exercise and Lumbar Multifidus Thickness  Berglund et al
Rehabilitative Ultrasound Imaging
Ultrasound imaging of the thickness of LM muscles at both
sides of the fifth lumbar vertebra was conducted by a PT
certified in ultrasound imaging using an EsaoteMyLab 25
Gold scanner with a 10–12 mHz linear probe. The partici-
pant being assessed was positioned on the examination table
in a pain-free, prone and relaxed position with both hands
under the belly and both index fingers on the navel. The
participants were first instructed to contract the muscles of
the trunk and thereafter relax, to ensure a measurement of
the LM muscles in a relaxed state. The LM muscle was
imaged in a transverse section allowing visualization of the
thoracolumbar fascia, muscle bulk, and transverse process.
The LM diameter was measured using on-screen calipers,
from the highest point of the thoracolumbar fascia in a
straight line to the vertebral lamina/transverse process of the
segment. To increase the intra-rater reliability, at the first
RUSI measurement the exact points of measurement along
with anatomical landmarks and typical characteristics such
as scars and birthmarks were marked on the lower back and
thereafter traced onto a transparent sheet. At the second
measurement, the same transparent sheet was placed over
the lumbar spine, thus enabling accurate relocation of the
imaging site. As per earlier studies4,13 the larger and smaller
sides (right or left) were determined to assess the thickness of
the LM muscle.
Data Analysis
Baseline values of age, body mass index (BMI), pain inten-
sity, and LM thickness were compared between the two
intervention groups and between men and women using
independent samples t tests. Paired samples t test was used to
compare baseline values of the small side versus large side
for men and women, respectively.
Linear mixed model (LMM) analysis was used to analyze
the effect of the intervention. For missing data, the last value
carried forward (i.e., percentage change equals zero) was
applied. The dependent variable was percentage change in
LM thickness. Fixed factors were Group (LMC, HLL),
Asymmetry (small side, large side), and Sex (male, female)
and the interactions for GroupAsymmetry, SexAsymmetry,
and SexGroup. Since no previous study has investigated the
relation between LM thickness and pain intensity in regard to
the effects of exercise interventions, separate analyses were
performed including: 1) baseline pain intensity and 2) pain
intensity change (baseline to follow-up) as covariates in each
LMM. BMI was also included as a covariate as suggested in
previous studies.10,24
A P value <0.05 was considered significant for
the analyses.
RESULTS
Participant attrition throughout the study is presented in
Figure 1. None of the participants in the LMC group
reported adverse effects, but one participant withdrew from
the study due to stomach surgery. In the HLL group, two
participants dropped out; one due to adverse effects and one
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 RANDOMIZED TRIAL Exercise and Lumbar Multifidus Thickness  Berglund et al

Figure 1. Flow of participants: low-load motor con-

trol exercises versus a high-load lifting exercise.

without giving an explanation. Mean attendance in the
LMC group was 6.0 (2.0) sessions and 11.0 (2.7) in the
HLL group. In the HLL group, the training intensity pro-
gressed from 20.0 (min–max 10.0–35.0) to 90.0 (55–200)
kg for men, and from 20.0 (10–20) kg to 55.0 (15–102.5)
kg for women.
There were no significant differences between the LMC
and HLL groups for baseline values (Table 1). The values for
LM thickness and percentage change are described in
Table 2. There were no significant differences between
intervention groups for the baseline values of the small or
large side of the LM muscles. Men had a significantly
(P ¼ 0.03) greater LM thickness on the large side and a
near significantly (P ¼ 0.06) greater LM thickness on the
small side at baseline compared with women. There was a
significant (P < 0.001) difference in thickness of the LM
muscle between the small and large side for both men
and women. This asymmetry ([thickness on large side -
 thickness on small side]/thickness on large side100)10
was 9.3% for men and 8.8% for women.

TABLE 2. Unadjusted Values (Mean and Standard Deviation) of the Lumbar Multifidus Thickness
(cm) at Baseline and at 2-Months Follow-Up, and Percentage Change from Baseline to
Follow-Up
n ¼ Baseline/ Large Side Large Side Large Side Small Side Small Side Small Side
Follow-Up Baseline Follow-Up Change (%) Baseline Follow-Up Change (%)
LMC n ¼ 33/32 2.70 (0.44) 2.68 (0.48) 0.41 (17.96) 2.46 (0.42) 2.62 (0.50) 7.95 (20.89)
HLL n ¼ 32/29 2.58 (0.47) 2.66 (0.60) 1.67 (14.13) 2.35 (0.45) 2.65 (0.51) 11.18 (18.08)
Men
All: n ¼ 28/28 2.78 (0.43) 2.80 (0.56) 0.71 (15.73) 2.52 (0.45) 2.66 (0.53) 6.38 (17.75)
LMC: n ¼ 13/13 2.83 (0.34) 2.71 (0.49) -4.14 (16.33) 2.59 (0.36) 2.62 (0.51) 1.35 (17.75)
HLL: n ¼ 15/15 2.73 (0.50) 2.87 (0.63) 4.91 (14.43) 2.46 (0.52) 2.70 (0.56) 10.73 (17.13)
Women
All: n ¼ 37/33 2.54 (0.45) 2.56 (0.49) 1.27 (16.54) 2.31 (0.41) 2.61 (0.48) 11.94 (20.60)
LMC: n ¼ 20/19 2.61 (0.48) 2.65 (0.48) 3.37 (18.75) 2.37 (0.45) 2.62 (0.50) 12.24 (22.10)
HLL: n ¼ 17/14 2.45 (0.40) 2.45 (0.50) 1.19 (13.64) 2.25 (0.37) 2.59 (0.46) 11.59 (19.39)

Number of participants out of total 65 at baseline and 61 at follow-up.
HLL indicates high-load lifting intervention group; LMC, low-load motor control intervention group.

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 RANDOMIZED TRIAL
For the LMM with baseline pain intensity and BMI as
covariates, the analysis for percentage change in LM thick-
ness showed a significant effect of Asymmetry (effect esti-
mate 9.58, 95% confidence interval [CI] 4.00–15.15,
P ¼ 0.001) in favor of the small side. There were no
significant effects for Group (P ¼ 0.522), Sex (P ¼ 0.349)
nor for the interactions (GroupAsymmetry, P ¼ 0.497,
SexAsymmetry, P ¼ 0.144 and SexGroup, P ¼ 0.162), or
the covariates baseline pain intensity (P ¼ 0.529) or BMI
(P ¼ 0.385).
For the LMM with pain intensity change and BMI as
covariates, the analysis for percentage change in LM
thickness showed a significant effect of Asymmetry (effect
estimate 9.58, 95% CI 4.00–15.15, P ¼ 0.001) in favor of
the small side. There were no significant effects for
Group (P ¼ 0.495), Sex (P ¼ 0.357) nor for the interactions
(GroupAsymmetry, P ¼ 0.497, SexAsymmetry, P ¼ 0.144
and SexGroup, P ¼ 0.178), or the covariates pain intensity
change (P ¼ 0.411) or BMI (P ¼ 0.336).
DISCUSSION
The results showed that LM thickness on the small side
increased significantly more over time compared with the
large side following both interventions and that neither
baseline pain intensity, nor change in pain intensity, affected
change in LM thickness. For the LMC intervention, the
increase in LM muscle size on the small side is in accordance
with the study by Hides,10 who found that cricket players
with LBP showed decreased LM asymmetry after 6 weeks of
motor control training. The finding that a high-load exercise
could have the same effect on the LM muscles has not been
previously shown, although at least two previous studies
have investigated this. In the study by Willemink et al,16
resistance training of the back extensors affected self-rated
function, but not LM size. In a study by Danneels et al18 a
combination of strengthening and motor control exercises
was superior in increasing the size of the LM muscles, when
compared to strengthening exercises or motor control exer-
cises, alone. Notably, Danneels et al18 did not regard asym-
metry; instead, used the sum of the cross-sectional areas of
the left and right LM muscles as outcome measure. We
believe that the reason why the deadlift exercise was effec-
tive, is that the participants were instructed to keep their
spine in a neutral position during the lift25,26 and to perform
Valsalva maneuver27 in combination with abdominal brac-
ing28 prior to the lifts in order to increase intra-abdominal
pressure,27 lumbar stability,29 and coactivation of all trunk
muscles.30 It has earlier been suggested that maintaining a
neutral lumbar position during the lift would optimize
biomechanical performance25 and activate31 the lumbar
muscles. In fact, abdominal bracing has been shown to elicit
a significant activation of the LM muscles in various pos-
itions.28 For both interventions it is possible that the neuro-
muscular stimuli32 on the small LM muscle was sufficient
enough to achieve hypertrophy. This is especially so if we
regard the asymmetry between sides as a consequence of
disuse of the small LM muscle,33 and therefore being more
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Exercise and Lumbar Multifidus Thickness  Berglund et al
receptive to short-term hypertrophic changes34 than the
large side, as shown by Hides et al.10
Regarding differences between sexes, the HLL exercise
might be more effective than LMC exercises to increase LM
thickness in men than in women. However, this observed
difference (Table 2) was not significant. We recommend
future studies to include a higher number of both men and
women to find out whether this is due to us having a limited
sample size.
The LMM analyses showed that neither baseline pain
intensity nor pain intensity change influenced LM thickness
change at the L5 level following interventions, as previously
indicated.11 We did not find these results surprising, since
the experience of LBP is complex and cannot be expected to
depend solely on a biological change of a tissue structure.35
Methodological Considerations
When using RUSI, the thickness of the LM muscle can only
be measured in a posterior-anterior direction, in comparison
with magnetic resonance imaging (MRI), which measures
area. When a recent study compared RUSI with MRI, poor
to moderate correlation between measurements were
found.36 However, RUSI measurements have commonly
been used2,7,37,38 and the fact that earlier studies37,38 present
similar values of LM thickness speaks in favor of the validity
of our measurements.
Second, since patients with nociceptive LBP seem to
experience less pain and disability than patients with other
dominating pain pattern,39 the results may not be applicable
for other subgroups of LBP.39
Third, there was a significant difference in number of
sessions attended between the intervention groups. The
reason for this was mainly a compliance issue; the partici-
pants in the LMC group did not want to attend all 12
sessions as they considered themselves adequately rehabili-
tated after about six sessions, which might have influenced
the effect on LM thickness for the LMC group.
CONCLUSION
The LM thickness in patients with nociceptive mechanical
LBP seems to be similar to healthy individuals and patients
with non-specific LBP. However, there was a difference in
thickness of the LM muscle between sides. It seems that
exercises focusing on spinal alignment, and thereby facili-
tating activation of stabilizing muscles, may increase the
thickness of the LM muscles on the small side and reduce
LM asymmetry between sides, irrespective of exercise load.
Moreover, an increase in LM thickness does not appear to
be mediated by either current pain intensity or the magni-
tude of change in pain intensity.
Key Points
The present study is the first to investigate the
effects of exercise on LM thickness in patients
August 2017
 RANDOMIZED TRIAL
with nociceptive mechanical LBP as their
dominating pain pattern.
Both low-load motor control exercises and a high-
load lifting exercise can reduce asymmetry of the
lumbar multifidus muscles by increasing the
thickness of the small side.
No association between changes in LM thickness
and pain intensity was found.
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