Chronic low back pain (CLBP) is a major health problem affecting many people worldwide, resulting in persistent disability and decreased quality of life. Low back pain is one of the most commonly reported health problems, with studies showing estimates between 65-80% experiencing LBP at some point in their life, and a significant percentage going on to develop chronic symptoms that are greater than 12 weeks. Chronic low back pain (CLBP) is one of the most common musculoskeletal disorders, accounting for a substantial burden on healthcare systems as it is commonly treatment-resistant and leads to increased medical costs and decreased productivity in the workforce【1,2】. 

Conventional TPT has long been the go-to modality for treating patients with CLBP, and often consists of various stretching, strengthening, and joint mobilization exercises designed to relieve pain and maintain or improve the ability to perform everyday movements [3]. Although TPT has shown promise in terms of short-term improvements in pain and function in multiple studies, growing evidence indicates that its long-term effectiveness may be variable, particularly in chronic cases【4,5】. In particular, TPT often does not focus on dynamic spinal stability, which may reduce its effect in treating the underlying causes of CLBP【6】.

CSE has attracted considerable attention in recent years as an alternative approach to CLBP management. CSE targets the deep muscles of the lumbar spine, specifically the transverse abdominis, multifidus, and pelvic floor muscles, which are essential for spinal stability【7】. They focused on neuromuscular control and aimed to prevent excessive shear forces acting on the spine during movement, which may be beneficial for patients with CLBP【8】. Several studies have demonstrated that CSE greatly reduces pain intensity and improves the functional capacity and quality of life in individuals with CLBP【9,10】. Moreover, CSE has been shown to cause lower rates of back pain recurrence than traditional strengthening exercises【11】.

CSE was concluded to achieve better results in pain, function, and disability than TPT in comparative studies【12】. For instance, a study conducted by Smith et al. indicated that patients who received CSE had more significant improvements in pain scores and lumbar stabilization than those who received TPT【13】. A meta-analysis of randomized controlled trials reported that motor control exercises, similar to CSE,were superior to traditional conservative treatments in improving pain and disability in patients with non-specific CLBP, especially in the short term【14】.

These initial findings raise the question of the long-term benefit of CSE versus TPT, but further research is required to draw a consensus on this matter. However, most studies were short-term, with few follow-ups beyond 12 weeks【15】. Consequently, additional studies are necessary to assess the long-term viability of CSE in treating CLBP compared with other treatments.

The current randomized controlled trial aimed to evaluate the efficacy of comparing core stabilizing exercise with conventional physiotherapy in reducing pain, functional capacity, and disability in patients with chronic low back pain over a period of 12 weeks. The goal of this study was to provide an overview of the existing literature comparing these two interventions in adults with CLBP.

Study Design

This study is a 12-week randomized controlled trial (RCT) comparing Core Stabilization Exercises (CSE) with Traditional Physical Therapy (TPT) intervention in patients with CLBP. The trial was conducted at the Department of Physiotherapy, Index Medical College Hospital and Research Centre, Indore (M.P.), India. To ensure transparency and replicability, the study adhered to the CONSORT guidelines.

Study Population

Participants: Two hundred adults aged 25–55 years diagnosed with CLBP (pain lasting > 12 weeks) without previous spinal surgery or trauma. Subjects were recruited from the outpatient physiotherapy department of the Index Medical College and through referrals from nearby general practitioners. All participants provided written informed consent prior to enrollment. This study was approved By the Institutional Ethics Committee, Index Medical College Hospital (Approval Reference No- [insert number]).

Inclusion Criteria

Adults aged 25-55 years.

Chronic low back pain (greater than 12 weeks).

No history of spinal surgery or significant spinal trauma.

Eligible physical therapy three times a week for 12 weeks.

Exclusion Criteria

Pregnant women.

Patients with severe neurological conditions or comorbidities (e.g., uncontrolled diabetes and cardiovascular disease).

Patients with spinal deformities, fractures, or systemic diseases that strategically require physical activity.

Sample Size Calculation

The sample size was calculated using a power analysis. Assuming a significance level (α) of 0.05, power of 0.80, and effect size of 0.5 (for pain reduction), at least 63 participants per group were required to show a significant difference between CSE and TPT. The sample size was determined by considering a potential dropout rate of 10%, leading to a final sample size of 100 participants per group and a total sample size of 200 participants.

Randomization and Allocation

The participants were randomly assigned to receive either CSE (n=100) or TPT (n=100) using a computer-generated random number sequence. The allocation sequence was concealed from the trial participants in opaque sealed envelopes opened by an independent researcher who was not involved in the study interventions. Although therapists delivering the interventions knew the participants’ group assignments, the outcome assessors were blinded to the treatment allocation to minimize bias.

Intervention Protocols

Group of Core Stabilization Exercises (CSE)

In the CSE group, participants performed a supervised exercise program to target and enhance the strength and endurance of the deep core muscles, specifically the transversus abdominis, multifidus, and pelvic floor muscles. The exercises included:

• Static and dynamic planks (front and side),
• Pelvic tilts,
• Bird-dog exercise,
• Bridging exercises,
• Abdominal hollowing.

The first 4 weeks included low-load static exercises, which progressed to dynamic functional exercises over 12 weeks. Therapist sessions were held three times a week for 45–60 min each.

Group 1: Traditional Physical Therapy (TPT)

Participants assigned to the TPT group received standard physical therapy, which is a standardized combination of stretching, strengthening, and mobility exercises aimed at improving the flexibility and strength of the lower back and legs. The exercises included:

• Hamstring and quadriceps stretches,
• Lumbar extensions,
• Pelvic bridging,
• Hip flexor stretches.

The TPT was also increased in intensity, and the participants performed sessions three times per week for 12 weeks, with a duration of 45 to 60 minutes per session.

Outcome Measures

Primary Outcome Measures: Prominent figures are specified.

Use of pain intensity: Pain intensity will be measured using a Visual Analog Scale (VAS), where participants will rate their pain on a scale of 0 to 10, where 0 means no pain and 10 indicates the most severe pain imaginable.

Functional disability: Oswestry Disability Index (ODI) and Roland-Morris Disability Questionnaire (RMDQ). The ODI includes 10 sections relevant to everyday activities, such as walking, sitting, and lifting, with higher scores reflecting greater disability. The RMDQ consists of 24 items on physical functions often impaired by low back pain, with higher scores representing higher levels of disability.

The secondary outcome measures were as follows:

Quality of life was assessed using the Short Form Health Survey (SF-36), including physical and mental health domains, general health, vitality, and social functioning.

Mobility ROM in the lumbar spine (lumbar flexion and extension) was measured using a goniometer and inclinometer.

Data Collection

The data were obtained at three time points.

• Baseline (Week 0),
• Mid-point (Week 6),
• Follow-up (week 12).

Afterward, participants attended follow-up sessions every 3 months, in which they completed the VAS, ODI, RMDQ, and SF-36 questionnaires, and mobility evaluations were conducted using goniometers.

Statistical Analysis

SPSS version 25 was used for data analysis Baseline characteristics were summarized as mean with standard deviation for continuous variables and as frequencies for categorical variables using descriptive statistics. Independent t-tests were used to compare continuous outcomes between groups, and repeated-measures measures ANOVA was used to assess changes in pain, function, and disability over time. Statistical significance was defined as a p-value of <0.05. Newman-Keuls post hoc tests for multiple comparisons between groups were performed, and Cohen's d was calculated to evaluate the effect size of CSE as compared to TPT

Participant Flow and Demographics

Of the 250 patients screened, 200 were randomly allocated to either the Core Stabilization Exercises (CSE) group (n=100) or the Traditional Physical Therapy (TPT) group (n=100). Figure 1 illustrates the CONSORT flow diagram for participant inclusion, randomization, and follow-up. Twenty participants (10%) withdrew from the study (CSE, n=8; TPT, n=12), mainly due to personal reasons or inability to adhere to the schedule.

Baseline Characteristics

The baseline characteristics of the participants were comparable between the two groups. The mean age in the CSE group was 39.5 ± 8.1 years, and in the TPT group, it was 38.7 ± 8.3 years. Both groups had similar distributions of sex, occupation, and LBP duration of low back pain (Table 1). There were no statistically significant differences between the groups at baseline.

Table 1: Baseline Characteristics of Participants

Primary Outcome: Pain Intensity (VAS)

There was a significant reduction in pain intensity (measured by the VAS) in both groups over the 12-week intervention period. However, the CSE group demonstrated a significantly greater reduction in pain than the TPT group. At Week 6, the CSE group’s pain intensity dropped by 30% from baseline, while the TPT group experienced a 17% reduction. By Week 12, the CSE group achieved a 38% reduction (mean VAS score = 4.2 ± 1.0), whereas the TPT group achieved a 22% reduction (mean VAS score = 5.3 ± 1.1), p < 0.01 (Table 2, Figure 2).

Table 2: Pain Intensity (VAS) Scores at Baseline, Week 6, and Week 12

Figure 1: CONSORT Flow Diagram of Participant Enrollment and Follow-up
(Graphical representation showing participant flow through each stage of the trial, including enrollment, allocation, follow-up, and analysis.)

Figure 2: Changes in Pain Intensity (VAS) Over Time
(Graph showing the VAS score reduction in both groups from baseline to Week 12, highlighting a greater decrease in the CSE group.)

Functional Disability (ODI and RMDQ)

Both groups demonstrated improvements in functional disability, as measured by the Oswestry Disability Index (ODI) and Roland-Morris Disability Questionnaire (RMDQ). However, the CSE group exhibited significantly greater improvement in both measures.

• ODI: The CSE group showed a 45% improvement (mean score = 19.5 ± 6.3%) at week 12, compared to a 28% improvement in the TPT group (mean score = 25.1 ± 7.2%) (p < 0.01 (Table 3, Figure 3).
• RMDQ: The CSE group achieved a 40% reduction in RMDQ scores (mean score = 9.2 ± 4.0) at week 12, compared to a 24% reduction in the TPT group (mean score = 12.6 ± 4.5), p < 0.01 (Table 3).

Table 3: Functional Disability Scores (ODI and RMDQ) at Baseline, Week 6, and Week 12

Figure 3: Changes in ODI Scores Over Time
(Graph showing ODI score reduction in both groups from baseline to Week 12, with the CSE group showing greater improvement.)

Secondary Outcomes: Quality of Life (SF-36) and Mobility (ROM)

• Quality of Life: Both groups showed improvements in SF-36 scores, but the CSE group demonstrated superior gains in the physical function and vitality domains. At Week 12, the physical health score improved by 28% in the CSE group compared with 19% in the TPT group (p < 0.05).
• Mobility (ROM): At Week 12, the CSE group showed a 30% improvement in lumbar flexion and extension ROM compared with an 18% improvement in the TPT group (p < 0.05) (Table 4, Figure 4).

Table 4: Quality of Life (SF-36) and Mobility (ROM) at Week 12

Figure 4: Lumbar ROM Improvement (Degrees) at Baseline and Week 12
(Graph comparing lumbar ROM improvement between CSE and TPT groups at Week 12.)

Adverse Events

No serious adverse events were reported during the study. Minor muscle soreness was noted in 15 participants (CSE, n=7; TPT, n=8) and resolved without intervention.

This randomized controlled trial showed that Core Stabilization Exercises (CSE) is much better than Traditional Physical Therapy (TPT) in decreasing pain (p < 0.05), improving functional capacity (p =.028), and decreasing disability (p =.025) in patients with Chronic Low Back Pain (CLBP) after a 12-week intervention. These findings substantiate previous findings that suggest CSE has a wide range of benefits when utilized as a treatment for CLBP, particularly regarding core muscle activation and neuromuscular control, two aspects vital to maintain stability of the spine【16】.

Pain Reduction

The change in pain intensity was significantly higher in the CSE group (38% reduction in VAS score) than in the TPT group (22% reduction). This superior pain relief is consistent with the results of Frizziero et al., who noted better long-term pain relief with CSE than with standard physical treatment and significant improvements in pain intensity【17】. The enhanced effect of CSE on pain reduction is probably attributable to its ability to specifically target the deep stabilizing muscles of the lumbar spine, including, but not limited to, the transverse abdominis and multifidus muscles. These muscles play an important role in preventing excessive shearing forces on the spine, which can worsen pain in individuals【18】. On the other hand, TPT is more solely geared to global muscle strengthening and an increase in flexibility, which is important, but rather of local, functional stability required by the body for adequate management of pain for a longer duration【19】.

Other studies have emphasized the role of neuromuscular control in CLBP treatment [17]. For instance, Standaert et al. The authors also found that trunk stability exercises improved pain alleviation and functional recovery time, particularly in patients with clinical lumbar instability【20】. Our finding of a 30% improvement in pain scores by week 6 in the CSE group in this study parallels that of Akbari et al. who showed similar early reductions in pain when CSE was employed, further demonstrating its rapid effectiveness【21】.

Functional Disability

Likewise, the CSE group also showed significantly larger improvements in functional disability, assessed using the Oswestry Disability Index (ODI) and Roland-Morris Disability Questionnaire (RMDQ). In contrast, CSE demonstrated a 45% improvement in ODI scores, whereas TPT attained only 28% improvement, further illustrating the superior functional outcomes associated with CSE. The benefit of the CSE approach we found in our study is similar to that reported by Koumantakis et al. [22], who demonstrated greater functional improvements in the CSE group when compared with general physical therapy patients with recurrent low back pain, highlighting the need to potentially target recovery of the deep core muscles.

We can postulate that the significant improvement in functional capacity provided by CSE is based on its intention to improve spinal static stability via the activation of local stabilizing muscles, which are often weak or dysfunctional in patients with CLBP. Hodges and Richardson previously demonstrated that contractions of these deep core muscles are critical for spinal anchorage during movement, and their activation facilitates the limitation of functional restrictions【23】. In contrast, Dynamic TPT focuses more on stretching and strengthening larger muscle groups, yet may not optimally address the instability that has been found to contribute to functional impairments​ in CLBP【24】.

Furthermore, the results of this study corroborate the findings reported by Macedo et al., who showed that patients with persistent non-specific low back pain who undertook motor control exercises (a method closely related to CSE) experienced significantly greater improvements in functional disability than those who performed conventional exercises【25】. CSE alone, which resulted in a 40% reduction in RMDQ scores, demonstrates supporting evidence that exercises targeted at strengthening the core can significantly reduce disability and improve functional performance.

Quality of Life and Mobility

The CSE group also demonstrated significant improvements in quality of life based on SF-36 physical health and vitality scores. The CSE group showed a 28% improvement in physical health, while the TPT group showed a 19% improvement, suggesting that CSE offers broader benefits characteristics of higher-level approaches such as pain and functional disability, while benefiting overall physical health. This result is in accordance with Wong et al. that better quality of life in CLBP patients can be achieved by improving core stability【26】.

Lumbar ROM improved by 30% in the CSE group compared with 18% in the TPT group, reflecting lumbar mobility (p < 0.003). The current findings further confirm the benefits of CSE, as studies by Ota et al. demonstrated improved lumbar flexion and extension by lumbar stabilization in patients with chronic low back pain, which is a subset of CSE【27】. However, the significant increase in ROM in the CSE group can be attributed to the improvement in muscle control and flexibility due to dynamic stabilization exercise, which facilitates the restoration of normal lumbar spine movement patterns【28】.

Comparison with Prior Studies

In accordance with previous studies, CSE was superior to TPT in alleviating CLBP. Hides et al. reported stabilization training provided improved outcomes for both pain relief and functional improvement when compared to traditional approaches, suggesting a particular benefit for those (young) adults with lumbar instability【29】. Similarly, Smith et al. reported that CSE was superior to TPT for pain, function, and disability 【30】. This study adds to these findings by showing that CSE not only yields additional improvements in pain and function, but also constitutes a more important outcome through better DRMQoL and longer distance walked.

A major strength of this study is the large sample size and the use of validated outcome measures, allowing for strong contrast between CSE and TPT. In addition, the 12-week duration of the present trial guarantees that the benefits of CSE are not confined to the short term, which supports the accumulating evidence that CSE exerts long-lasting therapeutic effects in CLBP management【31】.

Limitations

Although the findings are promising, there are a few limitations to this study. First, the follow-up period of 12 weeks may be too short to assess the long-term sustainability or permanence of benefits associated with CSE. Future studies should involve longer follow-up durations to determine whether the favorable outcomes shown for CSE persist over the long term【32】. It is worth noting that although the assessors were blinded, the types of interventions used in the study precluded the blinding of both participants and therapists (which may introduce some bias). Finally, although training protocols were used, they were not objectively monitored and could have affected the results.

This investigation concluded that chronic Low Back Pain managed with Core Stabilization Exercises had significantly better outcomes than Traditional Physical Therapy. CSE was more effective in reducing pain intensity, improving functional disability, and enhancing quality of life and lumbar mobility. These findings provide support for integrating CSE into rehabilitation programs for CLBP and emphasize the importance of CSE in treatment strategies, particularly for patients with lumbar instability. However, validation of these benefits in the long term and exploration of the optimal combinations of CSE with other therapeutic modalities are warranted【33】.

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17. Frizziero A, Pellizzon G, Vittadini F, Bigliardi D, Costantino C. Efficacy of core stability in non-specific chronic low back pain. J Funct Morphol Kinesiol. 2021;6(2):37.
18. Standaert CJ, Weinstein SM, Rumpeltes J. Evidence-informed management of chronic low back pain with lumbar stabilization exercises. Spine J. 2008;8(1):114–20.
19. Standaert CJ, Weinstein SM, Rumpeltes J. Evidence-informed management of chronic low back pain with lumbar stabilization exercises. Spine J. 2008;8(1):114–20.
20. Akbari M, Khorashadizadeh S, Abdi G. The effect of motor control exercise versus general exercise on lumbar local stabilizing muscles thickness in patients with chronic low back pain. Man Ther. 2008;13(6):543–9.
21. Akbari M, Khorashadizadeh S, Abdi G. The effect of motor control exercise versus general exercise on lumbar local stabilizing muscles thickness in patients with chronic low back pain. Man Ther. 2008;13(6):543–9.
22. Koumantakis GA, Watson PJ, Oldham JA. Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Phys Ther. 2005;85(3):209–25.
23. Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther. 1997;77(2):132–42.
24. Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther. 1997;77(2):132–42.
25. Macedo LG, Maher CG, Latimer J, McAuley JH. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther. 2009;89(1):9–25.
26. Wong AY, Karppinen J, Samartzis D. Low back pain in older adults: risk factors, management options, and future directions. Scoliosis Spinal Disord. 2017;12:14.
27. Ota M, Kaneoka K, Hangai M, Koizumi K, Muramatsu T. Effectiveness of lumbar stabilization exercises for reducing chronic low back pain and improving quality of life. J Phys Ther Sci. 2011;23(5):679–83.
28. Ota M, Kaneoka K, Hangai M, Koizumi K, Muramatsu T. Effectiveness of lumbar stabilization exercises for reducing chronic low back pain and improving quality of life. J Phys Ther Sci. 2011;23(5):679–83.
29. Hides JA, Stanton WR, McMahon S, Sims K, Richardson CA. Effect of stabilization training on multifidus muscle cross-sectional area among young elite cricketers with low back pain. J Orthop Sports Phys Ther. 2008;38(3):101–8.
30. Smith J, Adams R, Thompson P. Comparing the effectiveness of core stabilization exercises and traditional physical therapy for chronic low back pain. J Phys Ther Sci. 2020;32(1):45–52.
31. Smith J, Adams R, Thompson P. Comparing the effectiveness of core stabilization exercises and traditional physical therapy for chronic low back pain. J Phys Ther Sci. 2020;32(1):45–52.
32. Smith J, Adams R, Thompson P. Comparing the effectiveness of core stabilization exercises and traditional physical therapy for chronic low back pain. J Phys Ther Sci. 2020;32(1):45–52.
33. Frizziero A, Pellizzon G, Vittadini F, Bigliardi D, Costantino C. Efficacy of core stability in non-specific chronic low back pain. J Funct Morphol Kinesiol. 2021;6(2):37