Exercises for Chronic Low Back Pain:
A Clinical Trial
Finn )ohannsen, MD'
lars Remvig, Dr2
Peter Kryger, Dr3
Peter Beck, MD4
Susan Warming, PT5
Kirsten 1ybeck, PT6
Vivi Dreyer, PT7
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lone H. larsen, PT'
L
ow back pain (LRP) is a
major socioeconomic
Copyright © 1995 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
problem in the western
world (3,14,25), and con-
siderable effort has been
put into identifying risk factors (39).
Many studies have found that inade-
quate strength and endurance of the
back muscles are significant risk fac-
tors (1,3,2l); physical training pro-
grams have been prescribed as ther-
Journal of Orthopaedic & Sports Physical Therapy®
apy. Many different kinds of training
programs have improved function
and pain levels in patients with
chronic low back pain (9,11,12,22,23,
28,37,38). Williams' flexion exercises
have been a cornerstone in the man-
agement of LBP patient? for many
years (44). However, these exercises
were somewhat discredited when
Nachemson showed that they signifi-
cantly raised the intradiscal pressure
(34). Instead, isometric exercises
were advocated (22). Later, extension
exercises gained popularity, especially
after McKenzie showed that they had
a beneficial effect on recurrent low
back pain (30). However, other stud-
ies have not found any effect of iso-
metric o r dynamic back exercises
compared with placebo ultrasound
(29) o r short-wave diathermy (7). In
a recent review, it is concluded that
no consensus can be made about
Different training models are effective for the treatment of chronic low back pain, but no
consensus has been found. Earlier studies have emphasized training of spinal mobility and back
strength. To evaluate if other physiological parameters, such as coordination, are of equal
importance, we performed a randomized trial on 40 consecutive patients with chronic low back
pain. Two training models were compared: I ) intensive training of muscle endurance and 2) muscle
training, including coordination. In both groups, training was performed I hour hvice a week for 3
months. Pain score, disability score, and spinal mobility improved in both training groups without
differences between the two groups. Only intensive training of muscle endurance improved
isokinetic back muscle strength. At study entry, we found a significant correlation between spinal
mobility and dysfunction, but after the training, no correlation was found between improvement of
spinal mobility or isokinetic back extension strength and improvement of function or pain level. We
conclude that coordination training for patients with chronic low back pain is as equally effective as
endurance training.
Key Words: low back pain, muscle strength and endurance, coordination, proprioception
' Doctor, Department of Rheumatology, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke,
2400 Kobenhavn NV, Denmark
Supreme Doctor, Department of Rheumatology, Koge Hospital, Roskilde amt, Denmark
' Supreme Doctor, Department of Rheumatology, Hvidovre Hospital, University of Copenhagen, Denmark
Supreme Doctor, Department of Rheumatology, Frederiksberg Hospital, University of Copenhagen, Denmark
5-8
Physical Therapist, Department of Rheumatology, Bispebjerg Hospital, University of Copenhagen, Denmark
whether exercise therapy is better With proper practice/training, they
than other conservative treatments become smooth and easy (2). Spe-
for back pain or whether a specific cific coordinated reflexes p d u a l l y
type of exercise is most effective (24). develop through training of specific
Optimal muscle function does movements. This is called coordina-
not depend upon muscle strength/ tion training and does not necessarily
endurance and muscle flexibility increase muscle cross-sectional area
only. The coordination of movement? (muscle strength) (2). Coordination
is also of great importance. When training is essential to increase per-
unfamiliar and complicated move- formance in many sports and is also
ment? are performed, they are exe- used with success in the prevention
cuted clumsily and with difficulty. of injuries (43). Strength or endur-
Volume 22 Number 2 e August 19% JOSPT

ance training alone will primarily im-
prove the specific movements
trained. However, everyday life con-
sists of a wide spectrum of different
movements of the back, including
rotation and sidebending in different
degrees of back flexion and exten-
sion. Therefore, it appears logical to
train the coordination/propriocep
tion of patients with LBP in as many
different movements as possible with
limited and controlled load. Thereby,
coordinated reflexes will develop and
the movements will become smooth,
which might decrease the risk of I*
cally harmful stress forces.
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When unfamiliar
and complicated
movements are
Copyright © 1995 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
performed, they are
executed clumsily and
with difficulty.
Many studies have focused on
training of muscle strength/endur-
Journal of Orthopaedic & Sports Physical Therapy®
ance and/or mobility (9,11,12,22,23,
28,37,38), but we have found no
studies evaluating the effect of coor-
dination training. Therefore, we com-
pared coordination training with in-
tensive muscle endurance training,
which is a recommended treatment
for low back pain today (28.37).
MATERIALS AND METHODS
Subjects
Forty consecutive patients were
included in this study after informed
consent. All patients were admitted
to the Department of Rheumatology,
Bispebjerg Hospital, Copenhagen,
Denmark under the diagnosis of
chronic low back pain. Eligibility was
confined to patients aged 18-65
years with low back pain for more
than 1 year. The patients had back
JOSFT Volume 22 Number 2 August 1W5
RESEARCH STUDY
pain for at 1ea.t 3 months in the last
year, but were still employed. Those
with signs of nerve root compression
or evidence of spondylolisthesis, os-
teoporosis, painful osteoarthritis in
the lower extremities, inflammatory
rheumatic diseases, and neoplastic
disorders were excluded. X-rays of
the lumbar spine were performed
before inclusion. The X-rays were
evaluated by a trained radiologist. FIGURE 1. Endurance training. leg lifting. Standing by
with special attention to the exclu- the end of the couch, lean over to a prone position
with the hips against the edge in 90" ilexion, knees
sion criteria, disc degeneration, facet 454 and feet on the floor. If necessary, chest is fixated
joint arthrosis, spondylarthrosis, and to the couch by strap fixation. Both legs are lifted to
Morbus Scheuermann. the greatest possible extension in hips and spine. A
physiotherapist controlled that the legs moved sym-
metrically.
Procedure
All included patients were ran-
domized by stratification for sex, age
(older/younger than 40 years), dura-
tion of symptoms (greater/less than 2
years), and normal/abnormal X-ray
into two training models: endurance
training and coordination training.
The patient. were trained in groups
of up to 10 patients for 1 hour twice
a week during a Smonth period. Pa-
tients with more than 30% absence
from training were excluded from
the study. After the 3 months of su-
FIGURE 2. Endurance training. Trunk lihing. Prone on
pervised training, the patient5 were a couch, hips at the edge, upper part o l the body free
encouraged to continue exercises at but supported by the hands against the floor. Strap
home. This was not controlled. fixation over the calves. With hands on the head, the
trunk is lifted straight up to the greatest possible ex-
tension in hips and spine.
Endurance Training
Each session started with 10 min-
utes of warming up on a bicycle. Dy-
namic exercises emphaqizing muscle
endurance were performed for the
low back muscles (Figures 1 and 2),
abdominal muscles (Figure 3), mus-
cles around the shoulder girdle (Fig-
ure 4). and also the hip abductors,
hip adductors, and knee extensors.
All movements were strictly con-
trolled by strap fixation and physical
therapist supervision. The patients
were encouraged to do the greatest
possible extension in the hips and
spine, disregarding pain. Combined
FIGURE 3. Endurance training. Abdominal contrac-
movements and rotations were not tions. Supine crook lying. Knees flexed, feet flat on the
allowed. Each patient did as many couch without fixation. With arms on the head, slow
repetitions of each exercise as possi- sit-up exercises were performed straight forward.
 RESEARCH STUDY
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Copyright © 1995 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
FIGURE 4. Endurance training. Pull to neck. Sining on
a bench with the arms straight and abducted over the
head and hands grasping a weight lever. The lever is
pulled down behind the neck and shoulders with sub-
maximal load.
Journal of Orthopaedic & Sports Physical Therapy®
ble up to 100, with 30-second pauses
per 10 repetitions. As training was
limited to 1 hour per training ses-
sion, it was onlv possible to perform
approximately four different exer-
cises (Figures 1-4) when 100 repeti-
tions were reached. After each ses-
sion, 10 minutes of stretching of the
trained muscle groups were per-
formed ming static stretching for 30
seconds.
Coordination Training
Each session started with 10 min-
utes of warming u p on the floor, in-
cluding jogging. Exercises emphasiz-
ing coordination, balance, and sta-
bility were performed for the low
back, shoulder, and hip (Figures
-5-8).Each patient did u p to 40 repe-
titions of each exercise; it was possi-
ble to perform a wider variety of ex-
FIGURE 5. Coordin,ttion tr,tinin,q. St.trtin,q in ,I ~;r,~ndiny:
podion, thc l o w r 11,td is ror,ttrd to thr ri,qht and the upper
hack to the left while doing active ilevion exercises in the lefi upper extremitv and right lower extremitv. Aiter
touching the knee with the elbow, go back to the standing position with straight legs, arms, and hack. The exercise
is alternately performed with the left elbow touching the right knee and the right elbow touching the left knee.
ercises than the other group. Com- Com I1 (Chattecx Corp., Hixson,
bined movements and rotations were TN). T h e Kin-Com tnmk testing svs-
emphasized without fixation. All exer- tern is shown to be very accilrate in
cises were performed within a limited testing strength gains irrespective of
range of motion, respecting each pa- the training methods used (42). Pa-
tient's pain limits. After each session, tients were positioned as described by
10 minutes of stretching of the Smidt et al (42) in a sitting position
trained muscle groups were per- with 90" flexion in the hips and
formed using static stretching for 30 knees and with the pelvis and legs
seconds.
fixated. The resistance was placed on
the upper part of the sternum while
Evaluation measuring flexion strength and just
below the spine of the scapula while
All patients were evaluated bv the
measuring extension strength.
same two rmhlinded observers at en-
Recause LRP patient5 normally
try, after 3 months of training, and 6
months after entry. Isokinetic muscle have limited range of motion, we
strength doing hack extension and measured muscle strength in a 20"
hack flexion was tested using a Kin- range of motion of the trunk. An ini-
FIGURE 6. Coordination training. Positionedon the floor with both knees, hips, andshoulders flexed 90". The right
leg is extended to 0' in the knee and the hip, and the left arm is flexed to 180°. Rack to the starting position, and
then the exercise is repeated with the opposite extremities.
\'ohme 2 Numhcr 2' A l ~ q u s t19% -1OSPT

FIGURE 7. Coordination training. Supine crook Iving with knees f l e x 4 and feet flat on the floor. Sit-up exercises
with rotation of the back alternatelv to the k i t and to the right.
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tial torque overshoot is often seen in
isokinetic dynamometn. This is an
artifact not to be confi~sedwith tnle
muscular tension development (41 ).
Therefore, we truncated 3" of the
Copyright © 1995 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
cunre at the start of the trunk mo-
tion. Total work expressed by area
under the isokinetic strength curve
was chosen as it was found to be the
most reliable measure of isokinetic
muscle strength (42). An average of
three tests with slow angular veloci-
ties (IOO/sec,20°/sec, and 30°/sec,
respectivelv) was calculated, as the
Journal of Orthopaedic & Sports Physical Therapy®
reliability increases with slower test-
ing speeds (8).
FIGURE 8. Coordination training. Proprioceptive training on an ankle disk with a spherical undersudace. Try to
keep I)abnced while twistin,q and knee bending, standing on both ieet at the beginning and later on one leg at a
time.
I,ow hack pain patients are forlnd
to have reduced spinal mobility (32).
T h e sum of lateral flexion to both
sides measured with a tape as the dis-
tance the hand moves down the leg
during maximal lateral bending has
the best association with LRP (32).
This method is reliable (31) and has
been used in earlier studies on this
patient group (38). However, lateral
flexion is not forlnd to significantlv
improve during a training program
of flexion exercises and/or extension
exercises for LRP patients (38).
These training methods significantlv
improved the flexion measured as
RESEARCH STUDY
the fingertipfloor distance during
maximal fonvard bending (38). For-
ward and lateral flexion of the lum-
bar spine increases with lumbar lor-
dosis, but extension decreases. T h e
opposite is seen with increased thora-
cal kyphosis. Rv summing flexion and
extension, the biasing effect of lordo-
sis o r kyphosis is reduced (32).
Therefore, we chose to measure lat-
eral flexion to both sides, flexion and
extension, and calculate a mobility
score bv addition of the four mea-
sures in centimeters. Flexion was
measured using the modified
Schober test as described by Macrae
and Wright, who found this measure
reliable (26). Lateral flexion was
measured in standing position doing
maximal lateral flexion in the frontal
plane as described bv Ponte et al
(38) and reliability tested by Mellin
(31). We measured the fingertipknee
joint distance. If the fingertips were
above the knee joint, negative values
were measured. Extension was mea-
sured by sternal elevation (couch-
jugulum distance) while doing s u p
ported active extension lying prone.
Therebv, we found it unnecessaq to
fixate the pelvis as it was forced into
the couch. This testing method is not
as vet validated.
Rack pain at the time of evalua-
tion was registered on a .?point scale
(0-4). Average back pain in the last
week was registered on a similar
.?point scale. A pain score was calcu-
lated by addition of these two scales.
A similar method is used in the Claus
Manniche Low Rack Pain Rating
Scale (27).
Disability was estimated by asking
whether the patients felt impaired (1
point) o r not (0 point) in doing 12
evendav activities (dressing, rising
from a chair withoi~tusing the arms,
washing up, cleaning, shopping, driv-
ing a car, bicycling, bus riding, stair
climbing, walking, sleeping, and nor-
mal sexual activities). These activities
are common activities to all Danish
adults, and they were chosen as o u r
clinical experience has shown that
they were descriptive of Danish
 RESEARCH STUDY
chronic low back pain patients. The
number of impaired activities was
recorded as a disability score (0-12).
A similar method is used in the Claus
Manniche Low Back Pain Rating
Scale (27).
Drug consumption was registered
by counting number of patient. using
weak analgesics [paracetamol, non-
steroid anti-inflammatory drugs
(NSAID), acetyl salicyl acid (ASA)] or
strong analgesics (opiates) regularly.
The number of days on sick leave in
the last year before study entry and
during the study wa. also registered.
The classical way of measuring
treatment outcome is the patient's
overall assessment, meamred on a
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box scale by asking about their gen-
eral well-being (19). In our study, we
used a %point scale (1 = good, 3 =
bad), and, in order to analyze differ-
ences between the two treatment
Copyright © 1995 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
groups, the number of patients im-
proved, worsened, or unchanged dur-
ing the study was calculated.
Data Analysis
The Wilcoxon-Pratt test was used
to analyze changes in scores within
groups and the Mann-Whitney test or
Journal of Orthopaedic & Sports Physical Therapy®
Fisher's exact test was used to analyze
changes between groups. The Spear-
man test was used for correlation
analysis. The level of significance was
chosen at jK0.05 a pn'ori. Results are
given as the median with 12.5 per-
centiles.
Forty patients participated in this
study. Thirteen out of 20 accom-
plished 3 months of endurance train-
ing. Fourteen out of 20 accomplished
3 months of coordination training.
The entry characteristics of the pa-
tient. who accomplished the trial are
shown in Table 1. These two groups
were found to be comparable. Alto-
gether, 13 patients dropped out for
various reasons. These 13 patients
had an average of 134 days (range =
30-335) of sick leave due to back
Endurance ~ r a & n ~
N Median
Number of patients
Number of women
Age (years)
Weight (kg)
Height (cm)
Disability days due to back pain in
the last 12 months
Patient's general assessment (0-3)
Pain score (0-8)
Mobility score (cm)
Disability score (0-1 2)
lsokinetic back extension strength
(Nm)
lsokinetic back flexion strength
(Nm)
No differences between these two groups were found.
TABLE 1. Entry characteristics of patients who accomplishedthe trial (median and 12.5 percentiles).
pain within the last 12 months before
study entry. The same figures for the
patients who accomplished the train-
ing were an average 35 days (range
= 8-215 days). This is a significant
difference (jK0.05, Mann-Whitney).
Seventy-nine percent (22/28) of the
patients with less than 120 sick leave
days within the last year accom-
plished the training, but only 42%
(5/12) of the patients with more
than 120 sick leave days within the
laqt year accomplished the training.
Otherwise, no significant differences
were found between patients who
dropped out and patients who ac-
complished the trial.
The reasons for the seven d r o p
outq from the group that endurance
trained were increased pain (N=4),
lack of time (N=2), and general fa-
tigue (N= 1). The reasons for the six
dropout. from the group that coor-
dination trained were increaqed pain
(N=2), lack of time (N=l), dyspepsia
(N= 1). social reasons (N= 1), and
the start of other treatment (N= 1).
After 3 months of training, both
training groups showed significant
improvement in pain score, mobility
score, and disability score (Table 2).
These improvements were still signifi-
cant at the follow-up control after 6
months (Table 2). No differences,
however, could be found between the
Coordination Training
12.5 Percentile N Median 12.5 Percentile
two training groups with respect to
these parameters. Also, in overall as-
sessment, no difference was found
between the two groups (p= 1.00,
Fisher). Drug consumption was re-
duced to almost one-third in both
treatment groups without any differ-
ences between groups.
Isokinetic back extension
strength improved significantly in the
endurance trained group, but other-
wise no significant changes in isoki-
netic strength was found within or
between groups during the training
period (Table 2). At follow-up after 6
months, isokinetic back extension
strength was still significantly im-
proved for the endurance trained
group compared with the strength
assessment at entry. For the coordina-
tion trained group, a significant in-
crease in both isokinetic back exten-
sion and back flexion strength was
noted at follow-up compared with the
entry assessments.
Correlation analysis between the
subjective parameters (pain score,
disability score) and the objective
parameters (mobility score, back ex-
tension strength) showed significant
negative correlation between mobility
score and disability score pretrial
(p=0.009, R(S) = -0.425, Spearman).
Otherwise, no correlations were
found.
Volume 22 Number 2 August 1095 JOSPT

Assessed Parameter
Pain score (0-8) Endurance training
Coordination training
Mobility score Endurance training
(cm) Coordination training
Disability score Endurance training
(0-1 2) Coordination training
lsokinetic back Endurance training
extension Coordination training
strength (Nm)
lsokinetic back Endurance training
flexion strength (Nm) Coordination training
* Significant improvement compared with the assessment at entry, p<0.05, Wilcoxon-Pratt.
t Significant improvement compared with the assessment at entry, p<0.01, Wilcoxon-Pratt.
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No differences were found between the two training models.
TABLE 2. Effect of training on all assessed parameters (median and 12.5 percentiles).
In an effort to find a single fac-
tor responsible for the improvement
Copyright © 1995 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
in symptoms, we analyzed for a possi-
ble correlation between improvement
in the subjective parameters (pain
score, disability score) with improve-
ment in the objective parameters
(mobility score, isokinetic back exten-
sion strength). No correlation could
be found. X-ray abnormalities could
not be found to correlate with sever-
Journal of Orthopaedic & Sports Physical Therapy®
ity of back pain or training success.
DISCUSSION
The lifetime prevalence of LBP is
80% (16). Mostly, the complaints are
self-limiting, only lasting a few days
or weeks, but around 10% of patients
will suffer from chronic low back
pain (16). Weak trunk extensor en-
durance has been found to relate to
LBP and is, therefore, speculated to
be a cause of LBP (21). Thus,
strength/endurance training of the
back muscles has been recommended
and proven successful in the treat-
ment of chronic low back pain (28).
We found a significant improvement
of LBP after 3 months of endurance
training that significantly improved
back extension strength. Three
months of coordination training also
improved LBP, although no increase
JOSPT Volume 22 Number 2 Aupat 1995
At Entry
Median 12.5 Percentile
in back extension strength was found
thereafter. In our study, increased
back extension strength did not cor-
relate with LBP improvement. Thus,
we d o not think that back extension
training alone is the best training
model for patients with chronic low
back pain. In agreement with that,
other training models, such as dy-
namic flexion exercises, isometric
Three months of
coordination training
improved low back
pain, although no
increase in back
extension strength
was found.
abdominal exercises, and stretching
exercises, have also been found to be
effective in improving LBP (9.1 1,12,
22,23). The effect of all of these dif-
ferent training models might partially
be explained by improved nutrition
of the intervertebral disc induced by
motion (18) and partially by release
RESEARCH STUDY
3 Months 6 Months (Follow-up)
Median 12.5Percentile Median 12.5Percentile
of endorphines that modify the per-
ception of pain (15).
Low back pain is often associated
with decreased spinal mobility after
correction for age and anthropomet-
ric factors (32). Mellin found a corre-
lation between increased spinal mo-
bility and improved LBP symptoms
after a rehabilitation period with a
variety of exercises not aimed at in-
creasing spinal mobility (33). He con-
cluded that decreased spinal mobility
is a symptom of LBP and not a cause
of LBP (33). This is in accordance
with our results, as we found an in-
verse correlation between LBP score
and spinal mobility at entry, but no
correlation between increased spinal
mobility score and LBP improvement
was found. This means that increased
spinal mobility does not necessarily
lead to LBP improvement, and mobi-
lizing exercises alone cannot be rec-
ommended to LBP patients.
We could not find any correla-
tion of lumbar spine X-rays with back
pain severity and/or training effect.
This is in agreement with Dabbs and
Dabbs (6), who found no correlation
between disc height narrowing and
LBP. Low level of reliability in the
interpretation of lumbar spine X-rays
in back pain patients has been found
by Coste et a1 (5). Therefore, we con-
 RESEARCH STUDY
clude that X-ray is of little value for
the diagnosis and prognosis of LRP.
However, to diagnose contraindica-
tions for dynamic back extension ex-
ercises such as spondylolisthesis, neo-
plasm, and osteoporosis, X-ray is still
valuable (4,20).
We conclude that X-ray
is of little value
for the diagnosis
and prognosis of
low back pain.
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In our study, n o differences in
d r o p o u t rates from the two training
Copyright © 1995 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
models were found. Retrospective
analysis showed that it was not possi-
ble clinically o r with the help of X-
rays at entry to identify the patients
who could not complete the training
protocols. However, patients who
dropped out did have significantly
more sick leave days within the last
year before study entrance than pa-
Journal of Orthopaedic & Sports Physical Therapy®
tients who accomplished the training.
This is in agreement with Deyo et al
( l o ) , who found that the risk for LRP
chronicity increases with number of
days in bed. We agree with Fryrnoyer
(16) in finding that an increased
number of sick leave days increases
the risk for permanent working dis-
ability.
In Denmark, employees lose
their job after 120 sick leave days
within a year. This makes a psyche
logical borderline which our training
protocols did not succeed in over-
coming, as only 42% of all patients
above this borderline accomplished
the training. In an effort to help
these patients, other training models,
including psychosocial support,
should be tried. Hazard et al (17)
found that daily training for 53
hours/week, including behavioral,
social, psychological, and physical
training, for only 3 weeks was effec-
tive. Other studies also have optimis-
tic results for analog multidisciplinary
training models ( 1 3,40), although
Oland and Tveiten did not find them
worthwhile (35).
CONCLUSION
Rehabilitation of chronic low
back pain patients is difficult. Low
back pain is a multifaceted problem
and the pathogenesis is complex.
Training must be directed against
adjusting deficits o r imbalances. We
conclude that training models for
patients with chronic low back pain
should not emphasize only improve-
ment of spinal mobility and/or back
muscle strength. Other physiological
parameters, such as coordination,
seem to be of equal importance, es-
pecially as poor proprioception in a
recent study was also found to be a
significant risk factor for low back
injuries (36). Increased number of
sick leave days increases the risk for
chronicity, and physical training
models alone might therefore be un-
able to help patients with many days
of sick leave. For this group of pa-
tients, training models, including psy-
chosocial support, might be needed.
More studies are needed before we
can recommend any specific rehabili-
tation method. JOSPT
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