Sport Sciences for Health

https://doi.org/10.1007/s11332-020-00682-y

ORIGINAL ARTICLE

Impact of retrowalking on pain, range of motion, muscle fatigability,

and balance in collegiate athletes with chronic mechanical low back
pain
Sumbul Ansari1 · Shahid Raza1 · Pooja Bhati1

Received: 25 February 2020 / Accepted: 25 July 2020

© Springer-Verlag Italia S.r.l., part of Springer Nature 2020

Abstract
Background Low back pain (LBP) has been found to profoundly increase in athletes in the last decade. There are numerous
treatment options available for LBP of which retrowalking seems to be a promising option for these patients; however, its
potential utility in athletes is not known yet.
Aim To investigate the effect of addition of retrowalking to conventional exercises on pain, range of motion, muscle fatiga-
bility, and balance in collegiate athletes with chronic mechanical LBP.
Methods Subjects were screened using Oswestry Disability Index (ODI) and those having mild-to-moderate disability were
included in the study. A sample of 30 athletes were randomly assigned into two groups, retrowalking + conventional exercise
(n = 15) and conventional exercise (n = 15). Pain, flexion range of motion, balance, and muscle fatigability were examined
before and after 4 weeks of the intervention. Retrowalking group performed retrowalk on a treadmill at self-paced speed for
15 min/day for 3 days per week for 4 weeks along with the conventional exercises for back pain, whereas participants in the
control group performed conventional exercises alone for the same duration.
Results Significant differences were observed in pain (p = 0.003) and balance (p = 0.003) between the groups after the inter-
vention period, signifying greater improvement in the retrowalking group. No significant group differences were observed
for flexion range of motion (p = 0.97) and muscle fatigability (p > 0.05).
Conclusions Main findings of the present study suggest that retrowalking when added to conventional exercises may be
helpful in reducing chronic mechanical LBP and improving dynamic balance. Whereas retrowalking when combined with
conventional exercises has no additional effect in improving the flexion range of motion and reducing muscle fatigability.

Keywords Mechanical low back pain · Balance · Fatigability · Range of motion

Abbreviations Introduction
ODI Oswestry disability index
LBP Low back pain Low back pain (LBP) is nowadays one of the most widely
NPRS Numeric pain rating scale experienced health-related problems. The symptoms of LBP
EMG Electromyography usually appear between the age of 30 and 50 in general popu-
lation; however, it has been recorded in athletes in as early
as initial twenties [1]. LBP, in athletes, is a common pain
syndrome that accounts for 28% of missed training days per
* Shahid Raza year, with a prevalence rate of 39% for 12 months and a
mraza1@jmi.ac.in lifetime prevalence of 60% depending on the sport [2]. The
Sumbul Ansari number of collegiate athletes who experience LBP ranges
sumbulansari3@gmail.com between 1% and more than 30% [3–5]. Plentiful radiographic
Pooja Bhati evidence has shown that degeneration of the vertebral disc
pooja.bhati092@gmail.com was higher in athletes than in non-athletes [3–5], but these
1 studies [3–5] failed to establish the exact cause–effect rela-
Centre for Physiotherapy and Rehabilitation Sciences, Jamia
Millia Islamia (A Central University), New Delhi 110025, tionship. Higher rates of spondylolysis (defect or stress frac-
India ture in the pars interarticularis of the vertebral arch) have

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Vol.:(0123456789)

shown to be associated with repetitive back hyperexten-
sion movement such as diving, gymnastics, and wrestling
required in sports [3, 6]. Athletes suffer from LBP, which
limits their physical performance and puts them at risk of
early retirement from sports [2]. In various sports, LBP has
been considered as the cause of limited play and practice
[7]. Occurrence of LBP often leads to a shift in the athlete’s
focus from competition to rehabilitation [8]. LBP could be
classified as acute or chronic depending on its duration;
acute LBP is defined as the pain which persists for less than
6 weeks [9], pain that lasts for 12 weeks or longer is consid-
ered as chronic LBP, and 5–10% of all acute LBP patients
tend to develop chronic LBP [10]. Mechanical LBP can be
defined as back pain that arises intrinsically from the spine,
intervertebral discs, or surrounding soft tissues [11]. Various
anatomical structures could represent potential pain genera-
tors for LBP including bones, ligaments, joints, interverte-
bral discs, muscles, and neural structure [12]. Predisposing
factors that provoke the symptoms could be physical, such as
frequent lifting, vibration, heavy physical strain and postural
stress, or individual factors related to sex, age, posture body
height and weight, smoking, and heredity [13, 14].
Individuals having LBP tend to restrict their movement
and activity to avoid back pain and fear of causing injury
or harm [15]. People with chronic LBP generally present
with deconditioning of the extensor muscles identified as
reduced lumbar extension strength/endurance, atrophy, and
excessive fatigability, and it has been recognised that these
may be potential risk factors for low back injury and pain
[16]. Chronic LBP occurs in many people due to lumbar
instability caused by weakness of muscles around the spine
and soft-tissue damage in the trunk. Moreover, decreased
strength, endurance, and flexibility of muscles of the lumbar
region as well as limited range of motion of the joint cause
LBP to relapse [17].
Electromyographic spectral indices (such as median
frequency) and their shift to lower frequencies have been
validated as tools to monitor the local lumbar back extensor
fatigue in both healthy and LBP subjects [18]. Individuals
with chronic LBP tend to have impaired balance, mainly
during challenging balance conditions such as semi-tandem
and one-legged stance and balance assessment should be
considered in the rehabilitation programs for people having
chronic LBP for better clinical decision-making related to
balance re-training [19].
In the field of fitness and rehabilitation, retrowalking is
becoming increasingly popular nowadays. Retrowalking
is emerging as a beneficial exercise for improving oxygen
intake, cardiopulmonary fitness, and muscle activity while
simultaneously reducing stress on the joint [20, 21]. Gait
characteristics of backward walking are different from for-
ward walking and backward walking which has been found
to be more strongly associated with increased cadence and
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Sport Sciences for Health
decreased stride length than forward walking [21, 22].
Walking training could be incorporated in the rehabilita-
tion program of patients with LBP as the stability between
lumbar sections is low and coordination between the low
back extensors is poor [22]. Walking programs are help-
ful in simultaneously stabilizing the trunk and controlling
the movement of the limbs by strengthening the muscles of
the waist and the muscles of the abdomen that support the
spine [9].
Use of both backward walking and backward running in
the training of long-distance runners is encouraged owing
to increased activity of the knee extensors in these sports.
It has been shown that backward walking or/and backward
running has the potential to correct the imbalance between
the knee’s flexors and extensors, and also helps to adjust the
quadriceps to hamstring force ratio at an ideal value of 60/40
[23]. A significant difference between forward walking and
backward walking joint kinematic pattern is the pre-stretch
of the hamstring muscle that occurs in backward walking
prior to loading which potentially improves hamstring flex-
ibility [24]. Despite several studies done on retrowalking
to examine beneficial effects [8, 24, 25], there has been no
thorough scientific analysis of backward walking in regard
with chronic mechanical LBP in athletes. To the best of our
knowledge, no study till date has investigated the effect of
addition of retrowalking to the conventional exercises on
dynamic balance and muscle fatigability, although a few
studies have been done to check its effect on pain and range
of motion [8, 24]; however, considering several limitations
in these studies, it seemed that more scientific research needs
to be done to find out facts. Therefore, the purpose of this
study was to investigate the effect of addition of retrowalking
to conventional exercises on pain, range of motion, balance,
and muscle fatigability in collegiate athletes suffering from
chronic mechanical LBP. We hypothesized that addition of
retrowalking for 4 weeks to the conventional exercise pro-
gram will lead to significantly greater improvements in the
outcome measures assessed in the present study as compared
to the conventional exercise program alone.
Materials and methods
The present study was a two arm, parallel, randomized-
controlled trial.
Participants
The present study was approved by the Institutional Ethics
Committee, Jamia Millia Islamia, and was conducted in
accordance with the Helsinki Declaration of 1964. All par-
ticipants were informed about the procedures and potential
risks and were asked to sign a written consent form to
Sport Sciences for Health
participate in the study. The number of participants was
determined by G Power Software version 3.1.9.2 (Univer-
sity of Kiel, Kiel, Germany) using the data of changes in
pain before and after retrowalking intervention from a pre-
vious study [8] with an effect size of 1.03, α level of .05,
and power (1 − β) of 0.80. Based on these effect estimates
and adding 12% dropouts, a total sample of 30 participants
(15 participants in each group) were found to be necessary.
Subjects were included if they were of either gender, aged
18–30 years, had no radicular symptoms such as radiating
pain below knee or loss of sensation, an ODI score rang-
ing from 20 to 60%, mechanical LBP for > 12 weeks, and
it was thoroughly ensured by medical examination that
the participants did not experience any acute or chronic
cardiopulmonary and musculoskeletal problem (apart
from LBP). Subjects were not included in the study if they
had any recent trauma leading to body pain and postural
deformities, any previous surgery leading to body pain
and postural deformities, congenital postural deformities,
current pregnancy, nerve root compression (determined by
the presence of two or more of the symptoms-weakness of
myotomes, sensory loss of dermatomes, and hyporeflexia),
sacroiliac joint dysfunction (determined by any three posi-
tives among distraction test, Gaenslen’s test, thigh thrust
test, sacral thrust test, and compression test), or any meta-
bolic or vascular disease with a neurological component
such as diabetes or atherosclerosis. Based on these criteria,
30 university athletes suffering from chronic mechanical
LBP [age 23.33 ± 3.13 years, height 170.88 ± 8.55 cm,
weight 65.46 ± 8.88 kg, (BMI) 22.34 ± 2.1 kg/m2, limb
length 91.66 ± 6.46 cm] were recruited by convenience
sampling from the outpatient department of Centre for
Physiotherapy and Rehabilitation Sciences, Jamia Millia
Islamia, New Delhi, India.
Experimental procedures
All the experimental procedures were performed at the
Laboratory of Biomechanics, Centre for Physiotherapy
and Rehabilitation Sciences, Jamia Millia Islamia. After
recording the demographic measurements [age, height,
weight, body mass index (BMI), and limb length], par-
ticipants were subjected to baseline assessment of pain,
flexion range of motion, balance, and muscle fatigabil-
ity measurements 1 day prior to the beginning of the
intervention program. Pain intensity was assessed using
the Numeric pain rating scale (NPRS). Flexion range of
motion was measured using the modified Schober’s test.
Balance was measured using the Y-balance test kit and
muscle fatigability (of the lumbar multifidus, bilaterally)
was examined by EMG during the Sorensen’s test [median
frequency and its slope].
Pain
Pain was measured Numeric Pain rating scale (NPRS). The
11-point numeric scale ranges from ‘0’ representing “no
pain” to 10 representing “extreme pain/worst possible pain”
[26, 27]. The respondents were made familiar what does ‘0’,
‘10’, etc. means on the scale and were given a sheet having
the NPRS on it and they were asked to encircle the number
which indicates their pain during the past 24 h [28].
Range of motion
The flexion range of motion was measured by modified
Schober’s test using a measuring tape. A pen was used
to mark the midpoint between the posterior superior iliac
spines (PSIS). Thereafter, the measuring tape was utilized to
mark two important points: (1) 10 cm superior to the PSIS,
and (2) 5 cm inferior to the PSIS. The subject was asked to
flex the spine as far as possible and the distance between the
superior and inferior marks was recorded [29, 30].
Y‑balance test
Y-balance test is a tool that evaluates dynamic balance. The
aim of YBT is to maintain a single leg balance while maxi-
mizing reach by the contralateral leg. The YBT was per-
formed following the standard procedures [31]. The Y-bal-
ance test was explained and demonstrated to the participants
and three trails on each leg in all directions were practiced
by the participants before the actual testing (Fig. 1). The
limb length was measured from the anterior superior iliac
spine to the distal most point on the medial malleolus [32].
Reaching distance was normalized to limb length for allow-
ing comparison by dividing the reach distance by limb
length and then multiplying by 100. Composite reach dis-
tance was calculated by summing the distance of three reach
directions and then dividing it by three times the limb length
and then multiplying by 100 [31–33].
Electromyography (EMG) and Sorensen’s test
Skin preparation and electrode placement were performed
in accordance with the SENIAM guidelines [34]. Prior to
the experimental phase, each subject was prepared for EMG
recording as follows. Skin was prepared by shaving excess
hair and rubbing the skin with skin abrasive and alcohol
swabs to reduce impedance (typical ≤ 10 k Ω). Disposable
Ag/AgCl surface electrodes were attached parallel to the
muscle fiber orientation bilaterally. EMG surface elec-
trodes were placed on lumbar multifidus bilaterally, 2 cm
lateral to the midline running through the L5 spinous pro-
cess and aligned parallel to the muscle fiber [35] and refer-
ence electrode was placed over the C7 spinous process [34].
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Fig. 1  a Starting position of YBT, b subject performing anterior reach on YBT kit, c subject performing posteromedial reach on YBT kit, and d
subject performing posterolateral reach on YBT kit
Micropore tape was utilized to ensure adequate adherence
of surface electrodes to the skin. An interelectrode distance
of 20 mm was maintained between the electrodes. EMG
was recorded during the Sorensen’s test; the procedure for
this test is as follows—the subject was made to lie prone on
the examining table with the upper edge of the iliac crests
aligned with the edge of the table. Three straps attached the
lower body to the table, located on the pelvis, knees, and
ankles respectively [36]. With the arms folded across the
chest, the patient was asked to isometrically maintain the
upper body in a horizontal position. The subject was asked
to hold the position for as long as he/she could hold, the
test was stopped if the subject could not hold the horizontal
position accurately. Also, if the subject exceeded 240 s, the
test was stopped [36]. The time as well as EMG activity
were recorded during the period for which the subject kept
the upper body straight and horizontal [37]. The starting
position of the test was a flexed trunk (upper body sloping
towards the floor), so that an extension movement (concen-
tric contraction of the trunk extensor) was initially required
to reach a horizontal position [38]. For documenting the
horizontal position of the upper body, a visual evaluation
was done. [39].
EMG signal processing and analysis
EMG signals were recorded using Lab Chart software ver-
sion 7, AD instruments, New Zealand. All raw EMG signals
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Sport Sciences for Health
were analogue band pass-filtered between 10 and 500 Hz,
amplified (common mode rejection ratio > 100 dB, over-
all gain 1000, noise < 1 lV RMS), having a sampling rate
of 1000 Hz [39]. Average median frequency and its slope
during the test were recorded as EMG variables of muscle
fatigue during the Sorensen’s test. Each recorded EMG sig-
nal was divided in intervals of 1 s. The median frequency of
the EMG power spectrum was calculated in each 1 − s inter-
val with fast Fourier transforms (FFT). Median frequency
can be defined as the value that divides the area of spectrum
into two equal parts. Finally, linear regression analyses were
performed on the calculated median frequencies as a func-
tion of time to obtain a slope value [37, 39].
Exercise protocol
Subjects attended a supervised exercise program for 3 days
per week for 4 weeks. Subjects in retrowalking + conven-
tional exercise group underwent conventional exercises in
addition to retrowalking on a treadmill for 15 min in each
session. Retrowalking was performed on a motorized tread-
mill (JK EXER Treadmill, Cosco India Ltd, Gurugram,
India) for 15 min per day for 3 days per week for 4 weeks
at self-paced speed. Before starting the actual retrowalk-
ing, participants were familiarized with retrowalking on the
treadmill at self-paced speed. The actual exercise program
of retrowalking began once the subject was comfortable with
the process of retrowalking. Participants in the conventional
Sport Sciences for Health

exercise only group followed a conventional physiothera-
peutic exercise program which consisted of exercises such
as prone leg extension, prone lying chest elevation, prone
extension with alternate arm and leg lift, supine bridging,
bridging with one leg lift. 2 sets of 12 repetitions of each
exercise, each exercise position maintained for 10 s, and a
rest of 1 min between the sets were performed. No external
load/resistance was provided for the exercises, and the par-
ticipants performed the exercise within their available range
of motion [40].
Statistical analysis
Data are expressed as mean ± standard deviation and median
(interquartile range) when required. All the data were ana-
lyzed using SPSS Software version 17.0 (SPSS Inc., Chi-
cago, Illinois). The Shapiro–Wilk test was used to verify
the normality of quantitative data. Variables that demon-
strated non normal distribution were log transformed for
further analysis. Demographic characteristics (Table 1) and
criterion measures at baseline were compared between the
two groups by an independent t test. To test the difference
between the groups after the intervention, mixed model anal-
ysis of variance (ANOVA) with group (retrowalking + con-
ventional exercise versus conventional exercise only), time
(baseline versus post-intervention), and interaction effect
(Group × Time) was employed. Level of significance was
set at p < 0.05. There was a loss of four participants from the
study, they missed some of the exercise sessions and did not
come at the time of post-intervention outcome data measure-
ment. However, data were analyzed for all participants using
the intention-to-treat principle [41].
Results
Demographic characteristics of participants
At baseline, there were no significant differences between
the groups for demographic characteristics. Both the groups
were comparable in terms of age, height, weight, BMI, and
limb length (Table 1). There was no significant difference
between the groups at baseline measurement of outcome
variables as well.
Pain
Though pain was found to be not statistically different
between the groups at baseline (p = 0.96), significant differ-
ences were observed between the groups after intervention
period of 4 weeks (p = 0.003) with retrowalking + conven-
tional exercise group showing greater decline in pain than
conventional exercise only group [retrowalking, pre-to-post:
5 (2–7) to 1 (0–6), Control, pre-to-post: 5 (2–7) to 3 (1-5)]
Moreover, both groups showed significant within group
improvement in pain (Retrowalking, p = 0.001; Control,
p = 0.001).
Flexion range of motion
For the flexion range of motion, the results of mixed model
ANOVA showed significant main effect for time (p = 0.001),
whereas main effect of group (p = 0.97) and group × time
interaction (p = 0.93) were found to be insignificant indicat-
ing that flexion range of motion increased after both the
interventions, but there was no statistically significant differ-
ences in flexion range of motion after addition of retrowalk-
ing to conventional exercise program (Table 2).
Balance
For the normalized anterior reach distance, normalized pos-
terolateral reach distance, normalized posteromedial reach
distance, and normalized composite reach distance, the
results of mixed model ANOVA showed significant main
effect for time (p = 0.001) and group × time interaction for
these reach distance was also significant (p < 0.05), whereas
main effect of group was found to be insignificant for these
variables (p > 0.05), indicating that these reach distances
increased after the intervention, but there was no statisti-
cally significant difference after addition of retrowalking to
conventional exercise program (Table 2).

Table 1  Comparison of Variable Retrowalking + conven- Conventional exercises T value p value

demographic data between tional exercises
retrowalking and conventional
exercise group Mean (SD) Mean (SD)

Age (years) 22.3 (2.99) 23.3 (3.28) 0.87 0.39

Weight (kg) 66.4 (9.71) 64.4 (8.05) 0.68 0.50
Height (cm) 171.9 (8.85) 169.8 (8.26) 0.61 0.54
BMI (kg/m2) 22.3 (2.20) 22.3 (2.00) 0.09 0.92
Limb length (cm) 92.4 (6.78) 90.8 (6.15) 0.67 0.50

BMI: body mass index; data are presented as mean (SD); significant difference p < 0.05

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Table 2  Effect of retrowalking Variable Retrowalking + con- Conventional exercise p value

plus conventional exercise ventional exercise Mean (SD)
versus conventional exercise on Mean (SD) Time Time × group Group
outcome variables
FROM (cm)
Pre 19.6 (0.6) 19.6 (0.4) 0.001* 0.93 0.94
Post 20.8 (0.5) 20.3 (0.6)
ARDn (cm)
Pre 62.7 (8.8) 65.8 (3.7) 0.001* 0.004* 0.65
Post 68.5 (7.5) 66.5 (4.1)
PLRDn (cm)
Pre 87.2 (9.9) 92.1 (6.9) 0.001* 0.001* 0.38
Post 92.7 (10.3) 92.4 (6.4)
PMRDn (cm)
Pre 86.9 (8.8) 91.7 (6.5) 0.001* 0.001* 0.31
Post 92.0 (9.6) 92.6 (6.5)
CSn
Pre 78.9 (7.2) 83.2 (4.8) 0.001* 0.001* 0.32
Post 84.4 (8.0) 83.8 (4.6)
RTMF (Hz)
Pre 33.5 (1.1) 33.5 (0.8) 0.001* 0.29 0.47
Post 34.5 (0.5) 34.1 (0.5)
LTMF (Hz)
Pre 33.5 (0.7) 33.6 (0.6) 0.001* 0.33 0.64
Post 34.1 (0.5) 33.8 (0.6)
Sorensen’s time (s)
Pre 26.9 (14.4) 26.0 (8.9) 0.001* 0.53 0.88
Post 36.6 (14.4) 35.4 (10.2)
RT slope
Pre − 0.27 (0.12) − 0.30 (0.10) 0.001* 0.26 0.56
Post − 0.17 (0.07) − 0.17 (0.05)
LT slope
Pre − 0.29 (0.1) − 0.28 (0.1) 0.001* 0.82 0.86
Post − 0.18 (0.06) − 0.18 (0.04)

FROM flexion range of motion, ARDn normalized anterior reach distance, PLRDn normalized posterolat-
eral reach distance, PMRDn normalized posteromedial reach distance, CSn normalized composite score,
RTMF median frequency of the right multifidus during Sorensen’s test, LTMF median frequency of the
left multifidus during Sorensen’s test, Sorensen’s time hold time of the Sorensen’s test in seconds, RT slope
slope value of the right multifidus derived from the median frequency of each second of the Sorensen’s
test, LT slope slope value of the left multifidus derived from the median frequency of each second of the
Sorensen’s test
*denotes significant change

Muscle fatigability intervention, but there was no statistically significant differ-

For the Sorensen’s test hold time, median frequency of the
right multifidus during Sorensen’s test, median frequency
of the left multifidus during Sorensen’s test, slope value of
the right side, and slope value of the left side, the results
of mixed model ANOVA showed significant main effect
for time (p = 0.001), whereas main effect of group for these
variables was insignificant (p > 0.05) and the group × time
interaction effect for these variables were insignificant
(p > 0.05), indicating that these variables improved following
ence after addition of retrowalking to conventional exercise
program (Table 2).
Discussion
The present study was designed to investigate the effects of
addition of retrowalking to the conventional exercise pro-
gram on pain, flexion range of motion, muscle fatigability,
and dynamic balance in collegiate athletes suffering from

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Sport Sciences for Health
chronic mechanical LBP. The results of this study showed
that there was a significant improvement with time in all
variables in both the groups following the intervention, but
the reduction in NPRS score and improvement in balance
score was significantly greater in the retrowalking plus con-
ventional exercise group as compared to the conventional
exercise group alone.
The present study found a significant difference in the
NPRS score between the two groups after the interven-
tion period with greater reduction in pain in the retrow-
alking + conventional exercise group (Table 2). Although
lesser than the retrowalking group, pain was significantly
reduced in the conventional exercise group, as well. These
findings are consistent with the findings of previous litera-
ture, wherein a significant reduction in pain was observed
following a conventional exercise program in LBP patients
[42–44]. Greater reduction in pain scores after retrowalk-
ing could be attributed to retrowalking working on multi-
ple causative factors of LBP such as reduced core muscle
strength, disturbed pelvic alignment [3, 6] and hamstring
muscle flexibility. Retrowalking has been known for expo-
nentially improving the flexibility of the hamstring muscle
[24]. During retrowalking, there occurs greater hip exten-
sion and knee flexion as compared to forward walking which
along with a concomitant extension of the lumbar spine
loads the facet joints and helps in opening up the disc space,
causing a reduction in compressive loads to the interverte-
bral discs [25]. Moreover, heel strike associated with ground
contact is eliminated during retrowalking as the toe first
comes in contact with the ground, this change in kinematics
manifests as a greater anterior alignment of the pelvis and
this could potentially open up the facet joints and thus helps
to relieve pressure and reduces LBP [45]. Also, retrowalking
helps to improve strength of the muscles around the lumbar
region which could also be attributed to greater pain reduc-
tion after addition of retrowalking to conventional exercise
program in the present study [46].
Flexion range of motion improved in both the groups
after the intervention period; however, no group differences
were found (Table 2). People suffering from LBP frequently
show movement control impairments of the lumbar spine
in the sagittal plane [47]. Limiting movement and activ-
ity is largely voluntary, as people deliberately and uncon-
sciously limit or avoid back pain-inducing activities for fear
of causing injury or harm [15]. It is reasonable to suggest
that changes in afferent inputs due to perceived pain may
result in reflex inhibition of multifidus muscle that might
occur through a long loop. In LBP, afferent stimuli from
the multifidus area impair α motor neuron activation in the
spinal cord’s anterior horn. Spinal segmental movement,
therefore, decreases to protect structures against pathological
compromise. Inhibition of movements and activities usually
begins early in the course of back pain and can be reinforced
by health care providers by advising patients to avoid pain-
inducing activities and movements [48]. Reversal of func-
tional impairments of the low back can be approached using
established principles of exercise. These exercises certainly
help in alleviating pain and also help in further improvement
of limited range of motion [49].
There was a statistically significant difference with time
in the Y-balance test reach scores in both the groups after
both the interventions. Moreover, a significant group × time
interaction effect was also observed signifying greater
improvement in the retrowalking + conventional exercise
group than the conventional exercise group (Table 2). Bal-
ance dysfunctions in LBP can be explained by altered pro-
prioceptive feedback from the lumbar spine [50] which may
be due to dysfunction of the central integration of proprio-
ceptive information affecting mechanoreceptors [51]. People
anticipating pain perform activities less vigorously or may
avoid activity as a whole. In the sagittal plane, lumbar mul-
tifidus contributes more than two-thirds of the lumbar stiff-
ness and this muscle is primarily affected in patients with
chronic LBP. The preemptive co-contraction of the transver-
sus abdominis and multifidus before lower limb movement
helps to stabilize the trunk in anticipation of movement. This
linkage reduces joint forces and abnormal movements in dis-
tal segments [52]. In individuals with LBP, the protective
response is insufficient due to delayed anticipatory activation
[53]. The inability to activate the trunk muscles may create
an unstable pelvic base and lead to altered lower extrem-
ity neuromuscular control, and hence injury. Both routine
physiotherapy and the addition of stability exercise to the
conventional protocol seem to improve balance control and
reduce pain intensity and disability in LBP patients [54].
The exact mechanism through which retrowalking causes
improvement in balance and motor control is yet to be fully
elucidated. Retrowalking is more difficult and demanding
for the neuromuscular system than forward walking due to
postural instability and absence of visual cue to progress
which makes it potentially useful in the rehabilitation of
LBP. Retrowalking has shown to cause greater activation of
the multifidus and erector spinae muscles [40]. The possible
explanation for increased muscle activity during retrowalk-
ing when compared to forward walking might be attributed
to larger activations in the primary motor cortex, supple-
mentary motor area, parietal cortex, thalamus, putamen but
less activation in the cerebellum, and brainstem [55]. This
suggests that retrowalking creates more stability challenge
leading to a large number of motor unit recruitment which
results in greater amount of skeletal muscle activation [23,
56, 57]. Moreover, during retrowalking, the visual cue does
not provide the individual with visual information necessary
to anticipate ground conditions; therefore, there is a need to
organize and adapt the change in information from visual,
vestibular senses, and cutaneous and proprioceptive senses,
13

and then improve the movement control to maintain dynamic
balance [54, 58, 59].
There was a statistically significant change in the mus-
cle fatigability parameters with time in both the groups, but
there was no significant group and group × time interac-
tion effect. The mean Sorensen’s test hold time increased
by 9.6 s and 9.4 s in the retrowalking + conventional exer-
cise and the conventional exercise only group, respectively,
post-intervention (Table 2). There was a slight increase in
the median frequency and a less steep slope of the decline
in median frequency post-intervention in both the groups
signifying a decrease in the fatigability of the muscles post-
intervention, which is consistent with the findings of previ-
ous studies [60–62]. Findings of the present study suggest
that retrowalking did not seem to provide any additional
effect in reducing the muscle fatigability.
The decrease in median frequency during a fatiguing con-
traction is regarded as an objective measure of the fatigue
process, and in particular the slope of the regression line
of the median frequency on time is commonly used as an
indicator of muscle fatigability [18]. Slopes which are sig-
nificantly negative can be referred to as fatigue and slopes
not significantly negative as no fatigue or lesser fatigue [63].
The steeper the slope, the more fatigability and vice versa.
The assessment of paraspinal muscle fatigability is com-
monly based on the measurements of the maximum back
extension endurance [37]. Shift of the EMG frequency
towards the lower frequencies during fatigue is related to
biochemical by product accumulation (H+ and lactic acid)
in the muscle, which tends to change the action potential
conduction velocity. Also, other factors such as rate of firing
of the motor units, motor unit synchronization, additional
recruitment of motor units, and temperature influence the
changes in frequency [18]. This “myoelectric manifestations
of fatigue” is typically measured during a contraction as a
decrease in the median frequency of the electromyographic
signal. Individuals with better endurance would exhibit a
less precipitous decay rate of the median frequency [64]. In
the present study, the change in the median frequency slope
(less steep slope) after intervention represents a physiologi-
cal adaptation in the neuromuscular system. Some of the
more common adaptive processes associated with exercise,
such as muscle hypertrophy and change in muscle bioener-
getics, have been associated with median frequency [61].
Exercise progression through loading can decrease fatigabil-
ity of the back extensors, as measured by the Sorensen’s test.
Endurance is the time for sustaining a nonstationary activ-
ity, and increased endurance is supposed to develop through
light, repetitive loading [62]. Therefore, it is reasonable to
strive increased endurance through exercises, as observed
in the present study.
We did not measure median frequency changes of the
hamstring or the gluteus muscles or of other extensors that
13
Sport Sciences for Health
may have contributed to our performance measure (i.e.,
time). Median frequency measurements obtained from
more muscles would have provided with more sensitive
slope measurements. Use of surface electrodes for EMG
recording might have taken noises from other nearby mus-
cles also. During the Sorensen’s test, only visual analysis
of the horizontal position was done, and no equipments
were used to measure the degree of trunk sways. Another
limitation is absence of follow-up and absolute control
in the present study. Studies in future can be designed to
examine EMG activity of other important muscles such
as glutei, erector spinae, hamstring, etc. in these patients.
Retrowalking at different speed and inclinations of tread-
mill can be done to investigate the effect of speed and
inclination of treadmill on clinical outcomes in LBP
patients.
Conclusion
Results of the present study suggests that retrowalking has
an additional effect in pain reduction and balance improve-
ment when combined with the conventional physiotherapy
in athletes suffering from chronic mechanical LBP. How-
ever, it has no additional effects in decreasing fatigability
of the back muscles and in increasing range of motion
of low back in athletes with chronic mechanical LBP. In
summary, it could be inferred that addition of retrowalk-
ing to the conventional rehabilitation program could be
considered in athletes with LBP considering that it has
some potential benefits over conventional exercises in LBP
patients.
Acknowledgements We would like to admit to a sincere thanks to
Jamia Millia Islamia (A Central University) for providing logistic
help during the course of this study, and a sincere thanks to all the
participants of this study for showing their immense patience and co-
operation during the entire process.
Funding The present study was not funded by any external funding
agency.
Compliance with ethical standards
Conflict of interest Authors declare no conflict of interest pertaining
to this manuscript.
Ethical approval All procedures performed in the study were in accord-
ance with the ethical standards of the institutional/or national research
committee (Institutional Ethics Committee, Jamia Millia Islamia,
(Proposal No. 31/10/191/JMI/IEC/2018) and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
Sport Sciences for Health

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