Disability and Rehabilitation

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Clinical relevance of massage therapy and

abdominal hypopressive gymnastics on chronic
nonspecific low back pain: a randomized
controlled trial

Lorena Bellido-Fernández, José-Jesús Jiménez-Rejano, Raquel Chillón-

Martínez, Almudena Lorenzo-Muñoz, Elena Pinero-Pinto & Manuel Rebollo-
Salas

To cite this article: Lorena Bellido-Fernández, José-Jesús Jiménez-Rejano, Raquel Chillón-

Martínez, Almudena Lorenzo-Muñoz, Elena Pinero-Pinto & Manuel Rebollo-Salas (2021):
Clinical relevance of massage therapy and abdominal hypopressive gymnastics on chronic
nonspecific low back pain: a randomized controlled trial, Disability and Rehabilitation, DOI:
10.1080/09638288.2021.1884903

To link to this article: https://doi.org/10.1080/09638288.2021.1884903

Published online: 15 Feb 2021.

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DISABILITY AND REHABILITATION
https://doi.org/10.1080/09638288.2021.1884903

ORIGINAL ARTICLE

Clinical relevance of massage therapy and abdominal hypopressive gymnastics on

chronic nonspecific low back pain: a randomized controlled trial
Lorena Bellido-Fern
andeza , Jos
e-Jesu
nez-Rejanoa , Raquel Chillo

s Jime
n-Mart
ınezb ,
Almudena Lorenzo-Mun ~oza
, Elena Pinero-Pintoa
and Manuel Rebollo-Salasa
a
Department of Physiotherapy, University of Seville, Seville, Spain; bDepartment of Health and Sports, Pablo de Olavide University,
Seville, Spain

ABSTRACT ARTICLE HISTORY

Purpose: To determine the clinical relevance of the effects that Massage-Therapy (MT) and Abdominal- Received 21 August 2020
Hypopressive-Gymnastics (AHG) and the combination of both procedures have on the disability, pain Revised 29 January 2021
intensity, quality of life, and lumbar mobility of patients with chronic nonspecific low back pain (CNSLBP). Accepted 30 January 2021
Methods: A randomized controlled-trial with parallel-groups, concealed allocation, assessor blinding, and
KEYWORDS
intention-to-treat analysis was carried out. The sample included 60 adults with CNSLBP. The participants Chronic low back pain;
received MT (n ¼ 20), AHG (n ¼ 20), or MT þ AHG (n ¼ 20). Each group received 8 interventions. disability; exercise; massage
Results: The ODI change scores were significantly higher (p < 0.05) in the MT þ AHG group than in the therapy; quality of life
other two groups. Significant differences were found in the results of NRS, Schober’s test, and SF-12 PCS
(p < 0.05) in each group. There were significant differences (p < 0.05) between the values of SF-12 MCS in
AHG and MT þ AHG groups.
Conclusions: Massage Therapy and Abdominal Hypopressive Gymnastics reduce pain levels, increase the
mobility of the lumbar spine, and improve disability and quality of life (PCS) in patients with CNSLBP in
the short term. Likewise, AHG and MT þ AHG improve quality of life (MCS). The combination of both
therapies provides more benefits in terms of lumbar disability in patients with CNSLBP in the short term.
This improvement is clinically relevant.

Trial registration: ClinicalTrials.gov (NCT02721914).

ä IMPLICATIONS FOR REHABILITATION

 Massage Therapy (MT) and Abdominal Hypopressive Gymnastics (AHG), reduce pain, improve mobility
and quality of life, and reduce disability in the short term.
 These results are clinically relevant.
 The combination of manual and active therapy (MT þ AHG) seems to be more effective and produces
clinically relevant changes.

Introduction
Chronic low back pain is a major problem in modern health care
with high incidence. It is also one of the most disabling patholo-
gies that affects young adults [1]. Up to 90% of patients are diag-
nosed with nonspecific low back pain of which 2% to 7% will
eventually suffer chronic pain that interferes with their daily
lives [1,2].
Non-specific low back pain can be determined by problems in
the function of a patient’s body planes such as the thoracolumbar
fascia (support and level of movement), multifidus and abdomen
(as stabilisers of the spine), pelvic floor (support and load trans-
mission), the central nervous system (neuronal receptors and
upper motion control), and other psychosocial and behavioural
factors [3]. One exciting treatment area is non-pharmacological
therapies [3]. Several studies have combined passive and active
therapies to prevent and treat chronic low back pain [4–7].
Massage is one of the oldest passive treatments: It seeks nor-
malisation and global balance of the individual [4,8]. Massage
therapy (MT) stimulates tissue regeneration and reduces pain lev-
els [8,9]. This technique improves the circulatory, muscular, and
nervous systems [10,11]. Concurrently, exercise therapy is cur-
rently gaining ground because of its effectiveness in clinical and
scientific practice [3,12], but there is no clear evidence of a spe-
cific protocol [13]. One outstanding technique is Abdominal
Hypopressive Gymnastics (AHG). It involves postural exercises that
provide a decrease in pressure in the abdominal, perineal [14],
and thoracic cavities [15,16]. Abdominal hypopressive gymnastics
is a postural educational technique that teaches correct breathing
and posture [15]. It provides benefits such as strengthening the
abdominal muscles, rearranging the body posture, and increasing
flexibility of the lumbar spine and the ischiotibial muscles
[6,17,18]. Further, there is insufficient evidence that the addition
of massage to an exercise program provides short-term relief of
pain (Grade of Recommendation: I) [7].
Therefore, the objective of this clinical trial is to determine the
clinical relevance of the effects that massage therapy and abdom-
inal hypopressive gymnastics have on disability, pain intensity,

CONTACT Jos
e-Jes

us Jim
enez-Rejano josejesusjimenezrejano@gmail.com Department of Physiotherapy, University of Seville, C/ Avicena s/n, 41009 -
Seville, Spain
ß 2021 Informa UK Limited, trading as Taylor & Francis Group
2 L. BELLIDO-FERNÁNDEZ ET AL.
Figure 1. Abdominal hypopressive gymnastic protocol.
quality of life, and lumbar mobility of patients with chronic non-
specific low back pain, in the short term. We further evaluate a
combination of both procedures.
Methods
Study design
This study was a randomized controlled trial with three groups in
parallel. There was concealed allocation (using sealed opaque
envelopes), assessor blinding, intention-to-treat analysis and fol-
lows the CONSORT recommendations. It was developed in the
facilities of the Faculty of Nursing, Physiotherapy, and Podiatry
(Back School) of the University of Seville and lasted for
eight weeks.
Characteristics of the participants
The participants were recruited from the Back School of the
University of Seville. Eligible patients were aged between 20 and
65 years, had been diagnosed with chronic nonspecific low back
pain, had mechanical pain for at least 12 weeks, and had no
severe complications. The exclusion criteria were diagnosis of
arterial hypertension, progressive neurological deficit, pregnancy
or suspected pregnancy, and being under pharmacological or psy-
chiatric treatment [6]. All participants were selected by conveni-
ence sampling.
Interventions
The study development lasted for five weeks and involved 8 inter-
ventions of 30 min each excluding the learning time and the time
required for the different evaluations. For the first three weeks,
two weekly sessions were held (on Monday and Thursday or on
Tuesday and Friday); one weekly session was conducted during
the remaining two weeks [6].
A single specialist physiotherapist performed the treatment.
The different interventions were distributed as follows:
Group 1 received a massage therapy protocol focused on their
spine designed for the soft tissue of the thoracic lumbar and cer-
vical system, the entire fascial system, and the vertebral joints [6].
The massage considered the ergonomics of the physiotherap-
ist [8,9].
Group 2 performed a series of six static abdominal hypopres-
sive exercises (Figure 1). This method consists of postural exer-
cises that decrease the pressure in the abdominal, perineal [14],
and thoracic cavities [15]. The hypopressive exercises lead to dir-
ect activation of the transverse abdominal muscle, which
strengthens the abdominal girdle and stabilises the spine [14].
The participants repeated each exercise three times in addition to
a previous phase of learning and a minimum rest period [17].
Group 3 received four interventions of massage therapy and
another four interventions of abdominal hypopressive gymnastics
in alternating sessions.
Outcome measures
The registry of outcome measures was performed by a blinded exter-
nal assessor and was performed on three occasions: at the initial
evaluation (pre-test); in the middle of treatment (post-test 1) held on
the four weeks after the start of treatment; and at the end of the
interventions (post-test 2). Different scales and questionnaires were
used to measure four variables:
Primary outcomes
 Disability was measured using the Oswestry Disability Index
(ODI) (0%¼minimum functional disability; 100%¼severe func-
tional disability). This questionnaire is most commonly used
and recommended worldwide. The version adapted to the
Spanish population allows the clinician to obtain information
from the patient’s perspective, know the grade of efficacy of
the different treatment techniques used and compare results
with other studies published in the literature [19].
 The pain intensity was measured using the Numerical Rating Scale
(NRS) that ranges from 0 ¼ no pain to 10 ¼ maximum pain.

Secondary outcomes
 Quality of life was assessed using the SF-12 questionnaire. A
shortened version of the SF-36, which evaluates two dimen-
sions of health: Physical Component Summary (PCS), and
Mental Component Summary (MCS). It is transculturally
adapted to Spanish [20] and consists of 12 items of the SF-36
obtained from multiple regression. It can measure patients’
health and quality of life [20].
 Lumbar mobility was measured using Schober’s test. This test
is a valid and reliable tool to assess the range of motion of
lumbar flexion in patients with low back pain [21].
Data and statistical analysis
The free software Gpower version 3.1 was used to calculate the
required sample size. The data provided had an a error of 0.05
(confidence level [CI] of 95%), a b error of 0.2 (power of the study
of 80%), and a large effect size (f ¼ 0.5942) using a pilot study [6].
Under these conditions, the estimated sample size was 33
patients (11 in each group). Considering the possibility that the
intergroup differences found were smaller and that, therefore, the
effect size finally obtained was less than that indicated, 20 partici-
pants were finally included in each group. We then estimated the
effect size fell to f ¼ 0.415.
A blinded statistics specialist (other than those responsible for
the intervention, random allocation, and data collection) was
assigned to organise and analyse the data using the SPSS version
25.0 statistical package considering a confidence interval of 95%
(p value˂0.05) [6].
The effectiveness of the three applied interventions was exam-
ined using the intention-to-treat method comparing the three
groups (group 1: MT; group 2: AHG; and group 3: MT þ AHG). The
Shapiro-Wilk test was used to verify the normality of the sample
[6]. A descriptive data analysis was subsequently performed with
the outcome measures and baseline characteristics showing the
count and proportion of each category in the qualitative variables
and mean and standard deviation (SD) or, failing this, the median
and the interquartile ranges (IQR) of the quantitative variables.
In the variables that were not adjusted to normal, Friedman’s
ANOVA test was used to analyse the differences between the
measurements considering each group individually. The repeated-
measures ANOVA test was used for variables that were adjusted
to normal. Next, the difference between the pre-treatment value
(baseline) and post-test 1 and between the pre-treatment value
and post-test 2 was calculated. These values are called the change
scores. The percentage change score was also calculated [22,23].
The differences between the treatment groups were analysed in
the change scores using the ANOVA test of a factor in the varia-
bles that were adjusted to the normal and complemented by the
Scheffe test; the effect size was ascertained by determining the
value of the coefficient partial eta2. The effect size of the differen-
ces between each pair of groups compared was also calculated
using Cohen’s coefficient.
Finally, the Kruskal-Wallis ANOVA test was used in the change
scores that did not adjust to the normal complemented with tests
of pairwise comparisons.
Results
Flow of participants through the study
The participants were recruited between April 1 and May 27,
2016. The sample included 60 subjects with a mean age of
36 years (SD of 14) and was comprised of 45 women and 15
MASSAGE THERAPY AND ABDOMINAL HYPOPRESSIVE GYMNASTIC 3
males who were divided into three groups in a random manner
into group 1 MT (n ¼ 20), group 2 AHG (n ¼ 20), and group
3 MT þ AHG (n ¼ 20). Trial flow is presented in Figure 2, and the
baseline characteristics are shown in Table 1. This table demon-
strates that there were no differences in any of the variables con-
sidered before starting the interventions, that is, the three groups
were homogeneous at baseline.
Effectiveness of interventions
The results are shown in Table 2. This table shows the differences
between the three measurements of each dependent variable
when considering it in each intervention group individually.
Statistically significant differences were seen in the three groups
between the baseline and post-test 1 and between the baseline
and post-test 2 (p < 0.05), i.e., the ODI, NRS, Schober’s test, and
the PCS component of the SF-12 quality of life variables.
Statistically significant differences were also observed for the MCS
component of the SF-12 quality of life in the AHG group between
the baseline and post-test 2 (p < 0.001) and in the MT þ AHG
group between the pre-test and the remaining measurements
(p < 0.05) (Table 2).
The comparison between the three groups is presented in
Table 3. Significant differences were found when comparing the
change score of the ODI variable from the baseline to post-test 2
in the three groups. Specifically, significant differences were dem-
onstrated between the MT þ AHG group versus the other individ-
ual groups. These data show that the combined therapy group
significantly improved their disability (variable ODI) between the
baseline and post-test 2 measurements (p < 0.05).
Discussion
The percent change in the ODI between post-test 1 and the base-
line and between post-test 2 and the baseline was greater than
50% for the three groups. This indicates that this value was higher
than the minimal clinically important difference (MCID) in the out-
come measures [22,24].
When the groups were compared clinically (Table 3), we found
differences in the change scores between post-test 2 and the
baseline of the ODI scale within the MT þ AHG group unlike the
other two groups. When the MT group was compared with the
combination therapy group, there was a difference of 14.4 points
(on a scale of 0–100), and the difference was 13.4 points (on a
scale of 0–100) between MT þ AHG versus AHG. Asher et al. [25]
found MCID values from 3.3 to 26.6 points (on a scale of 0–100),
and thus the differences seen in our trial can be considered clinic-
ally relevant. Likewise, Chou et al. [26] and Ostelo et al. [27] pro-
posed a value greater than 10 points (on a scale of 0–100) as
minimally important changes (MIC).
The NRS scale has been used in other studies on chronic low
back pain [23,28–30], and those values are similar to our data.
The score change between post-test 2 and the baseline in the
three groups were four points, this is more than the two points
seen in by Farrar et al. and Childs et al. [23,28] as the MCID.
Further, the change score percentages of the NRS between post-
test 2 and the baseline surpassed the 30% indicated by these
authors as the MCID [27].
D
ıaz-Arribas et al. [31] found a MCID of 3.29 points via the PCS
component of the SF-12 questionnaire. The score change seen in
our trial was higher in all three interventions. The MCS compo-
nent in D
ıaz-Arribas et al. [31] had a MCID of 3.77 points; there-
fore, the differences found in our study were better than prior
4 L. BELLIDO-FERNÁNDEZ ET AL.

Figure 2. The study flow diagram.

Table 1. Baseline characteristics.

MT AHG MT þ AHG
n ¼ 20 n ¼ 20 n ¼ 20
Variable Median (IQR) Median (IQR) Median (IQR)
Age (years) 43 (25–57) 27 (22–42) 34 (24–52)
Gender Female 15 (75%)a 16 (80%)a 14 (70%)a
Height (m) 1.64 (1.59–1.69) 1.65 (1.62–1.71) 1.63 (1.59–1.73)
Weight (kg) 70 (59.5–78.8) 60.9 (56–75.8) 59.8 (56.5–74)
BMI (kg/m2) 25.7 (4)b 23.6 (3.4)b 23.8 (2.4)b
ODI, scores 0–50 25.6 (9.8)b 24.1 (10.5)b 28.7 (7.5)b
NRS, scores 0–10 7 (6–7.8) 6.5 (5–8) 7 (7–8)
Schober (cm) 5.2 (4.5–5.9) 5.9 (4.5–6.6) 5.1 (4.7–5.8)
SF-12 PCS, scores 0–100 42.9 (38.3–46.9) 42.9 (38.9–49.9) 43.2 (39.4–45.5)
SF-12 MCS, scores 0–100 43.2 (12.3)b 44.3 (8.7)b 42.0 (8.9)b
a
Count and proportion are shown.
b
Mean and Standard Deviation (SD) are shown.
AHG: Abdominal Hypopressive Gymnastics; IQR: Interquartile Range; MCS: SF-12 Mental Component Score; MT: Massage Therapy; PCS: SF-
12 Physical Component Score.
 MASSAGE THERAPY AND ABDOMINAL HYPOPRESSIVE GYMNASTIC 5

Table 2. Primary and secondary outcomes: differences within groups.

Measure Median (IQR) Within-Group Difference
3
measurements Pretest vs Pretest vs
Outcome Measure Group Pretest Post-test 1 Post-test 2 comparison Post-test 1 Post-test 2
ODI, scores 0–50 MT 24 (18–34.5) 10 (6–15.5) 8 (4.5–14) p < 0.001 p < 0.001 p < 0.001
AHG 24 (14.5–34) 12 (4.5–15.5) 8 (4–13.5) p < 0.001 p < 0.001 p < 0.001
MT þ AHG 29 (22.3–34) 13 (8.5–14) 6 (4–9.5) p < 0.001 p < 0.001 p ¼ 0.003
NRS, scores 0–10 MT 7 (6–7.8) 5 (4–6) 3 (1.3–4.8) p < 0.001 p ¼ 0.008 p < 0.001
AHG 6.5 (5–8) 5 (2.3–6) 2 (1–3.8) p < 0.001 p ¼ 0.004 p < 0.001
MT þ AHG 7 (7–8) 6 (4–6) 2 (1–3.8) p < 0.001 p ¼ 0.004 p < 0.001
Schober (cm) MT 5.2 (4.5–5.9) 6.5 (5.9–6.9) 6.8 (5.9–7.4) p < 0.001 p ¼ 0.005 p < 0.001
AHG 5.9 (4.5–6.6) 6.3 (5.3–6.9) 6.6 (5.9–7.3) p < 0.001 p ¼ 0.006 p < 0.001
MT þ AHG 5.1 (4.7–5.8) 6.1 (5.6–6.6) 6.7 (6.1–6.9) p < 0.001 p ¼ 0.002 p < 0.001
SF-12 PCS, scores 0–100 MT 42.9 (38.3–46.9) 51.3 (47.7–54.8) 52.5 (48.9–54.2) p < 0.001 p < 0.001 p ¼ 0.001
AHG 42.9 (38.9–49.9) 49.1 (46.8–53.9) 51.8 (46.5–52.7) p ¼ 0.003 p ¼ 0.03 p ¼ 0.005
MT þ AHG 42.2 (7.4) 48.4 (5.4)a 51.4 (4.2)a p < 0.001 p ¼ 0.001 p < 0.001
SF-12 MCS, scores 0–100 MT 44.9 (35.8–51.5) 48.6 (40.4–51.5) 52.7 (47.5–56.7) p ¼ 0.09 p ¼ 0.64 p ¼ 0.051
AHG 42.4 (37.9–53.1) 50.5 (43.7–56.4) 58.2 (53.6–60.1) p < 0.001 p ¼ 0.25 p < 0.001
MT þ AHG 42.9 (35.3–48.4) 51.2 (47.2–55.9) 54.1 (51.4–57.4) p < 0.001 p ¼ 0.03 p < 0.001
a
Mean and SD are shown.
AHG: Abdominal Hypopressive Gymnastics; IQR: Interquartile Range; MCS: SF-12 Mental Component Score; MT: Massage Therapy; PCS: SF-12 Physical
Component Score.

Table 3. Primary and secondary outcomes: differences between groups.

Within-groups change scores Between-groups change scores
Median (IQR) p Value / Cohen’s d
p Value / MT vs AGH vs
Outcome measure MT AHG MT þ AHG Partial Eta2 MT vs AHG MT þ AHG MT þ AHG
ODI, scores 0–50
Post-test 1
Change score 13.6 (8.4)a,c 13 (8.5)a,c 16.5 (8.9)a,c p ¼ 0.41 p ¼ 0.98 p ¼ 0.58 p ¼ 0.45
% Change score 53,8 (26,8)c 52 (27,4)c 54,5 (20,1)c Eta2 ¼ 0.03 d ¼ 0.07 d ¼ 0.33 d ¼ 0.40
Post-test 2
Change score 15.2 (9.1)b,c 15.7 (7.5)b,c 22.4 (7.7)b,c p ¼ 0.012 p ¼ 0.98 p ¼ 0.03 p ¼ 0.04
% Change score 67,4 (51,7–80) 63,6 (53,9–80,4) 80 (71,7–86,9) Eta2 ¼ 0.15 d ¼ 0.06 d ¼ 0.85 d ¼ 0.88
NRS, scores 0–10
Post-test 1
Change score 2 (1–3)a 2.5 (2–3)a 1 (1–3)a p ¼ 0.28 p ¼ 0.63 p ¼ 0.99 p ¼ 0.50
% Change score 28,6 (14,9–42,1) 35,4 (25–50) 17,1 (14,3–42,1)
Post-test 2
Change score 4 (2–5)b 4 (4–5)b 4 (4–6.5)b p ¼ 0.20 p ¼ 0.73 p ¼ 0.29 p ¼ 0.99
% Change score 57,3 (27,1)c 68,2 (22,7)c 67,8 (23,7)c
Schober (cm)
Post-test 1
Change score 0.8 (0.1–1.7)a 0.5 (0.1–1.1)a 0.6 (0.3–1.6)a p ¼ 0.42 p ¼ 0.80 p ¼ 0.99 p ¼ .76
% Change score 14,9 (2–36,9) 8,1 (2,2–23,9) 11,3 (4,7–32)
Post-test 2
Change score 1.3 (0.7–2)b 0.5 (0.2–1.6)b 1.4 (0.7–2.2)b p ¼ 0.07 p ¼ 0.32 p ¼ 0.99 p ¼ 0.07
% Change score 25,7 (12,9–40,9) 7,8 (3,5–34,4) 26,9 (12,3–47,3)
SF-12 PCS, scores 0–100
Post-test 1
Change score 7.5 (6.9)a,c 5.7 (6.6)a,c 6.2 (6.9)a,c p ¼ 0.69 p ¼ 0.71 p ¼ 0.83 p ¼ 0.98
% Change score 12,9 (3,9–37,2) 13,8 (3,8–27,2) 17,5 (0,3–28,2) Eta2 ¼ 0.01 d ¼ 0.26 d ¼ 0.19 d ¼ 0.07
Post-test 2
Change score 7.7 (5.8)b,c 6.5 (6.8)b,c 9.2 (6.8)b,c p ¼ .43 p ¼ 0.84 p ¼ 0.78 p ¼ 0.43
% Change score 19,1 (15,9)c 16,4 (16,8)c 24,8 (21,8)c Eta2 ¼ 0.03 d ¼ 0.19 d ¼ 0.24 d ¼ 0.40
SF-12 MCS, scores 0–100
Post-test 1
Change score 3.9 (12.3)a,c 5.3 (11.7)a,c 7.8 (7.9)a,c p ¼ 0.52 p > 0.92 p > 0.53 p > 0.77
% Change score 4,6 (10–32,9) 11,3 (0,7–32,6) 18,8 (9,5–39,9) Eta2 ¼ 0.02 d ¼ 0.12 d ¼ 0.38 d ¼ 0.25
Post-test 2
Change score 7.4 (9.4)b,c 11.4 (10.6)b,c 11.4 (9.1)b,c p ¼ 0.32 p > 0.42 p > 0.43 p > 0.99
% Change score 24,3 (31,7)c 29,4 (30,2)c 32,8 (31,3)c Eta2 ¼ 0.04 d ¼ 0.40 d ¼ 0.43 d < 0.01
a
Change scores between baseline and post-test 1.
b
Change scores between baseline and post-test 2.
c
The difference within-Groups Change Scores are shown (mean and SD).
AHG: Abdominal Hypopressive Gymnastics; IQR: Interquartile Range; MCS: SF-12 Mental Component Score; MT: Massage Therapy; PCS: SF-12 Physical Component
Score; SD: Standard Deviation.
6 L. BELLIDO-FERNÁNDEZ ET AL.
work for all three groups. Thus, the changes are considered clinic-
ally relevant in all outcome measures in all three groups.
Other authors have studied the effects of MT in low back pain.
Cherkin [9] and Sritoomma et al. [32] highlighted the decrease in
pain levels, Visual Analogue Scale (VAS), after 10 massage sessions
and the improvements in the patients’ functional capacity (ODI-
Roland-Morris Disability Questionnaire) after the short-term inter-
vention ended. These data agree with our results although the
participants in our research had fewer sessions (less rehabilitation
costs), and the groups that received MT demonstrated improve-
ments in the pain indexes (NRS), disability (ODI), mobility
(Schober’s test), and quality of life (SF-12).
Field [11] assessed MT and relaxation-contraction exercises and
reported increased spine mobility measured across the range of
joint width and range of motion (ROM). Yu et al. [33] also
reported a significantly greater improvement in mobility in a man-
ual myofascial therapy group versus that after exercise. However,
Anderson [34] found a significant increase in joint mobility (ROM)
in a Pilates exercise group compared to a group that received MT.
In our trial, all groups had an increase in the flexibility of the col-
umn (Schober’s test).
We have not found studies which have investigated the use of
abdominal hypopressive gymnastics to treat chronic nonspecific
low back pain; therefore, our results can also be compared to
other active therapies. Da Luz [35] and Miyamoto et al. [36] used
Pilates exercises as the main intervention while Halliday [37] and
Garc
ıa et al. [30] used the McKenzie method. These studies
obtained significant results in pain and disability levels.
Magalhaes [38] combined aerobic exercises with strength training
and found significant changes in pain, disability, and patient
mobility without differences versus other conventional treatments.
We are not aware of any study that combined MT with hypo-
pressive abdominal gymnastics, however, many papers have com-
bined MT with other therapeutic exercise interventions objectives.
One combination therapy treatment (MT plus exercise) offered
better results in terms of disability (ODI) versus the same treat-
ment used individually [5]. Zhang et al. [5] applied MT with a core
training protocol and stabilisation of the trunk musculature. This
reduced pain levels (VAS) and disability (ODI) more significantly
than an individual exercise protocol. Ajimsha et al. [39] obtained
similar results by combining myofascial therapy and exercise, and
the benefits were superior to individual manual therapy. Similar
results have been shown in other studies [5,6,39]. Combination
therapy was more effective in the short term (after 8 sessions of
intervention) than individual protocols. Massage therapy and exer-
cises focused on abdominal recovery and spinal elongation (AHG)
might be more effective: Fewer sessions (lower intervention costs)
still improved the patients’ pain and functional capacity.
Zhang et al. [5] found a low incidence of relapse in subjects
who received a Chinese massage type along with abdominal
strengthening exercises (core) and stabilisation of the trunk mus-
culature. However, these were long-term results obtained after
many sessions (40 in total over 8 weeks) versus the eight interven-
tions used here. This increases the costs of rehabilitation.
A limitation of this trial was that the physiotherapist who
administered the treatment could not be blinded by the charac-
teristics of the study. Likewise, this study focused on determining
the clinical relevance of the effects of a procedure that had never
been used in rehabilitation for the treatment of chronic nonspe-
cific low back pain, such as hypopressive abdominal gymnastics,
as well as its comparison with massage therapy and the combin-
ation of both. This has provided preliminary evidence of the
clinical relevance of these effects in the short term. It is necessary
to study this relevance in the long term.
Conclusions
Massage Therapy and Abdominal Hypopressive Gymnastics reduce
pain levels, increase the mobility of the lumbar spine, and
improve disability and quality of life (PCS) in patients with chronic
nonspecific low back pain in the short term. Likewise, AHG and
MT þ AHG improve quality of life (MCS). The combination of both
therapies provides more benefits in terms of lumbar disability in
patients with chronic nonspecific low back pain in the short term.
This improvement is clinically relevant.
Acknowledgments
The authors thank all participants in this study and acknowledge
the Faculty of Nursing, Physiotherapy and Podology of Seville for
making this project possible.
Ethics approval and consent to participate
Prior to this work, an approval (C.I. 2384) was obtained from the
Research Ethics Committee of the Virgen Macarena University
Hospital Centre from Seville (Spain). This human work was con-
ducted in accordance with the 1964 Helsinki Declaration and its
later amendments or comparable ethical standards. Written and
verbal information was provided to all the subjects via informed
consent. The subjects were included in the study after signing a
consent form.
Disclosure statement
The authors declare that there is no conflict of interest.
ORCID
Lorena Bellido-Fern
andez http://orcid.org/0000-0002-4419-1174
Jos
e-Jesu

s Jim
enez-Rejano http://orcid.org/0000-0003-
3358-3305
Raquel Chillo
n-Mart
ınez http://orcid.org/0000-0003-0282-3556
Almudena Lorenzo-Mun ~oz http://orcid.org/0000-0002-
8750-4177
Elena Pinero-Pinto http://orcid.org/0000-0001-9611-3939
Manuel Rebollo-Salas http://orcid.org/0000-0003-2788-0725
Data availability statement
The datasets generated during and/or analysed during the current
study are available from the corresponding author on reason-
able request.
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