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Core Stability Exercises for Low Back Pain in Athletes: A Systematic Review of the Literature

Stuber, Kent J. DC, MSc*; Bruno, Paul DC, PhD; Sajko, Sandy DC, MSc; Hayden, Jill A. DC, PhD§

Clinical Journal of Sport Medicine: November 2014 - Volume 24 - Issue 6 - p 448–456
doi: 10.1097/JSM.0000000000000081
General Review
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Objective: The aim of this study was to systematically review the evidence for the effectiveness of core stability exercises for treating athletes with low back pain (LBP).

Data Sources: We searched several databases (Medline, AMED, CINAHL, SportDiscus, and EMBASE). Our eligibility criteria consisted of articles published in a peer-reviewed journal in English, using any prospective clinical study design, where athletes with nonspecific LBP were treated with core stability exercises in at least 1 study arm, and back pain intensity and/or disability were used as outcome measures. All included randomized controlled trials (RCTs) were assessed for risk of bias using the Cochrane Risk of Bias tool, whereas non-RCT studies were assessed for quality using the Downs and Black checklist.

Main Results: Five studies including 151 participants met the inclusion criteria, including 2 RCTs. The quality of the literature on this topic was deemed to be low overall, with only 1 non-RCT having a moderate quality score, and 1 RCT having a lower risk of bias. Four studies reported statistically significant decreases in back pain intensity in their core stability intervention group.

Conclusions: The quantity and quality of literature on the use of core stability exercises for treating LBP in athletes is low. The existing evidence has been conducted on small and heterogeneous study populations using interventions that vary drastically with only mixed results and short-term follow-up. This precludes the formulation of strong conclusions, and additional high quality research is clearly needed.

*Division of Graduate Education & Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada;

Faculty of Kinesiology and Health Studies, University of Regina, Regina, Saskatchewan, Canada;

Sports Clinic, University of Toronto Mississauga, Mississauga, Ontario, Canada; and

§Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.

Corresponding Author: Kent J. Stuber, DC, MSc, 19-8 Weston Dr SW, Calgary, AB T3H 5P2, Canada (kstuber@cmcc.ca).

Dr. K. J. Stuber helped conceive and design the review, conducted the searches and article retrieval, and participated in the analysis and interpretation of the data. Dr. P. Bruno and Dr. S. Sajko helped conceive the review and participated in the analysis and interpretation of the data. Dr. J. A. Hayden helped conceive and design the review and participated in the analysis and interpretation of the data. Dr. K. J. Stuber, Dr. P. Bruno, Dr. S. Sajko, and Dr. J. A. Hayden participated in drafting and revising the article and provided final approval of the version to be published.

The authors report no conflicts of interest.

Received January 03, 2013

Accepted December 23, 2013

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INTRODUCTION

Low back pain (LBP) is common in athletes. The 1-year prevalence of LBP has been reported to be 68% among top athletes from multiple sports;1 studies on specific sports have reported 1-year prevalence of 49% in orienteering,2 54% in wrestlers,1 86% in gymnasts,3 and 94% in hockey players.1 Comparatively, the reported 1-year prevalence of LBP in the general population varies from 22% to 65%.4 Although the results of 2 studies suggest that the prevalence of LBP in athletes is similar to that of the general population,2,5 1 study investigating the prevalence of LBP among Australian Rules football players indicated that it was higher than in a nonathletic control group.6

Depending on the sport, athletes require their lower backs to have the capacity to tolerate high loads and perform complex repetitive movements.7–9 It is well documented that certain forms of spinal injury are more common in athletes than in the general population. For example, 33% of elite American football linemen were found to have hyperconcavity of the vertebral endplates with expansion of the disk space compared with 8% of age-matched controls,10 although this does not seem to have an effect on lumbosacral spine symptoms or duration of playing career.11 Degenerative disc disease is more common in elite athletes than nonathletes.12–14 Spondylolytic injuries seem to be more common in some sports than others (eg, American football, rowing, diving, gymnastics, martial arts, rugby), with throwing sports, in particular, having higher rates of spondylolytic injuries.7,14–18 American football linemen produce nearly 7 times their body weight in compressive force and 2.6 times their body weight in shear force on the L4–L5 segment when blocking; with repetition, these forces may increase the risk for fatigue failure and injury.7 Cricket bowlers place high compressive loads on their spines during the power phase of the throw because of the frequent repetition of high velocity lumbar movements in a very specific sequence.9,18 Gymnasts also place large vertical and lateral impact forces on their spines,19 and overuse has been implicated as a potential risk factor for back injury in this population.18

There are many possible treatment options for LBP in athletes including medications, biopsychosocial interventions, physical and electrical modalities, manual therapies, and exercise therapies.20 Among exercise therapies, there are different forms of exercise that can be prescribed for LBP, including stretching or mobility exercises, cardiovascular endurance or aerobic exercises, and strengthening exercises.21 One form of strengthening exercise that has received increasing attention in the literature and popular media is “core stability exercise.” This type of exercise is variably defined as any exercises that strengthen spinal musculature or specifically as those that emphasize the deep lumbopelvic musculature (eg, transversus abdominis, multifidus).22 There is some evidence that exercises thought to target these deep muscles are effective in treating chronic LBP in the general population.23,24 However, it has also been argued that focusing on 1 or 2 deep muscles in core stability exercise programs is misguided because both deep and superficial muscles contribute to spinal stability.25–29 McGill et al28 state that “any exercise that grooves motor patterns, that ensure a stable spine, through repetition, constitutes a ‘stabilization’ exercise.” A recent meta-analysis that defined core stability exercise broadly as “the reinforcement of the ability to insure stability of the neutral spine position” reported that such exercises are more effective than general exercise in treating chronic LBP in the general population.30

Differences in the athlete compared with the general population (eg, higher physical demands, repetitive motions, and higher baseline fitness level) warrant assessment of treatment evidence specifically for this population. The aim of this study was to systematically review the available evidence for the effectiveness of core stability exercises for athletes with LBP.

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METHODS

We conducted and reported this systematic review according to the PRISMA guidelines,31 with a protocol defined a priori. We searched 5 online databases (Medline, AMED, CINAHL, SportDiscus, and EMBASE) from the start date of the respective database through the last week of June 2012 with no language restrictions, using a comprehensive set of MeSH and key word terms referring to athletes, LBP, and core stability exercises (Appendix for the Medline search strategy). Two reviewers (K.J.S. and S.S.) independently screened the titles and abstracts for potentially applicable studies, and full-text reports of potentially eligible citations were retrieved for final selection. Any disagreement on inclusion was discussed and mediated by a third author (J.A.H.) when necessary. We searched reference lists of all included studies to identify other potentially relevant studies. Included studies had to meet specific criteria (Table 1). Two of the authors (P.B. and S.S.) independently extracted data from the included studies into a prespecified electronic data extraction form, which was subsequently reviewed by a third author (J.A.H.).

TABLE 1

TABLE 1

Critical appraisal of included studies was conducted independently by 2 authors (K.J.S. and P.B.) with a third author (J.A.H.) resolving any differences. All included randomized controlled trials (RCTs) were evaluated using the Cochrane Back Review Group modification of the Cochrane risk of bias tool.32 Randomized controlled trials were deemed to have a low risk of bias if they had ≥6 of the 12 risk of bias criteria scored as low risk.33 Non-RCT studies were assessed for quality using the Downs and Black checklist.34 Non-RCT studies were deemed to be high quality for scores of ≥21 on the checklist, moderate quality for scores between 11 and 20, and low quality if they scored ≤10.35 Statistical significance (set at P < 0.05) for between-group differences and within-group differences over time was used to interpret positive results. To determine whether minimal clinically important differences were achieved between groups in the included studies, we considered a 20-point (out of 100) or 2-point (out of 10) improvement in pain intensity and a 10-point (out of 100) improvement in functional measures to be clinically important.36 We also considered a minimum average of 30% improvement within groups from baseline to be clinically important.36

Two of the authors (K.J.S. and P.B.) independently applied the GRADE criteria37 for interpreting the overall quality of the available evidence. Using this framework, high quality evidence indicates that further research is very unlikely to change our confidence in the estimate of effect, moderate quality evidence indicates that further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate, low quality evidence indicates that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate, and very low quality evidence indicates that any estimate of effect is very uncertain.

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RESULTS

Search Results and Study Designs

We identified 677 potential citations and screened 9 full-text articles (Figure). Four of the 9 articles were excluded because of poor reporting of the LBP subgroup and a lack of pain intensity reporting38 or because the intervention did not specifically include core stability exercises.38–41 Five studies met all selection criteria and were included in the review: 3 observational studies42–44 and 2 RCTs.45,46Table 2 presents a description of included studies.

FIGURE

FIGURE

TABLE 2

TABLE 2

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Participants

Sample sizes of included studies ranged from 744 to 50 (25 participants per group).42 All of the participants in 1 study were women,43 whereas only men participated in the remaining studies. In 2 studies, the participants were middle-aged and older.42,46 The participants were adolescents in 1 study,43 whereas in the remaining 2 studies, the average age of the patients was in their early twenties.44,45 Sports involved included cricket,44 field hockey,45 ice hockey,46 teamgym gymnastics,43 and a variety of sports.42 The participants had either acute LBP,43 chronic LBP,42,46 or a mixture of subacute and chronic LBP.45

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Outcome Measures Used

For all included studies, outcomes were assessed during and/or after intervention only, between 3 and 12 weeks after baseline.42,43,46 None of the studies performed long-term follow-up assessments after their postintervention assessments. Four studies used the visual analog scale (VAS) to measure pain intensity;42,44–46 the remaining study used the Borg Category Ratio Scale.43 One study46 used the Oswestry Disability Index (ODI) and short-form 36 questionnaire (SF-36) in addition to the VAS. Three studies used some form of physical function outcome measure.42,45,46

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Intervention Type

The core stability exercises evaluated in the included studies varied. One study used machine-based strengthening exercises for the low back and abdomen,42 whereas another used a full-body strengthening program that combined machines, free weights, and body-weight exercises targeting the abdominal and lower back muscles (eg, crunches performed using a Swiss ball, prone “Supermans,” traditional abdominal crunches).46 Two of the studies involved exercises where participants cocontracted the transversus abdominis and multifidus muscles and progressed from easier to more complex positioning and the use of unstable surfaces.43,44 The remaining study45 used “dynamic muscular stabilization technique,” which also involves a progression of resistance and more difficult positioning through different stages.

Control/comparison group interventions also varied widely between the studies—for example, therapeutic ultrasound, short-wave diathermy, and floor-based lumbar strengthening exercises (which could also be considered a form of core stability exercise);45 Souchard postural exercises with stretching and unweighted abdominal and back muscle strengthening exercises (potentially another form of core stability exercise);42 and regular training and recreational activities.43,46 One observational study did not include a control or comparison intervention.44

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Primary Study Outcomes: Back Pain and Disability

Table 3 depicts the results of the included studies. Two RCTs (45 participants) and 3 nonrandomized studies (47 participants) provided information on the effect of core stability exercises on pain and disability outcomes. Four of the 5 studies reported a statistically significant improvement in average pain intensity for their core stability intervention groups,42,44–46 and clinically meaningful differences in average pain intensity were observed in 3 of the 5 studies.42,44,45 Average pain intensity in both core stability intervention groups in the study by Jackson et al46 demonstrated statistically significant but not clinically important improvement over time, whereas the average pain intensity in their control group increased by the end of the trial. Two studies42,45 reported statistically significant improvement in pain intensity in their comparison treatment groups over time.

TABLE 3

TABLE 3

Two RCTs (75 participants) and 2 nonrandomized trials (69 participants) provided information on the effect of core stability exercises compared with other treatments. One study45 noted statistically significant and clinically important improvements in pain intensity, favoring the core stability intervention group over their conventional treatment group (which included lumbar strengthening). Jackson et al46 noted statistically significant but not clinically important improvements in pain intensity in both of their core stability intervention groups compared with the control group, with no statistically or clinically significant differences noted between the 2 intervention groups. The remaining studies42,43 did not find statistically significant or clinically important differences in pain intensity between their intervention and comparison groups.

Jackson et al46 found that disability due to LBP (ODI) showed statistically significant and clinically important improvement in both of their intervention groups compared with the control group, with no statistically significant or clinically important differences noted between the 2 intervention groups.

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Secondary Study Outcomes: Functional Testing and Global Health Findings

Jackson et al46 found statistically significant increases in strength for all of the functional measures assessed (bench press, leg press, lat pulldown) in both of their intervention groups compared with the control group. One study42 found statistically significant increases in peak isokinetic torque at 60 degrees per second for the lumbar flexors and extensions in the intervention group, whereas the comparison group demonstrated a statistically significant increase in peak isokinetic torque at both 60 degrees per second and 120 degrees per second. Another study45 found statistically significant improvements in all functional measures assessed (walking, stand-ups, and climbing) in their intervention and comparison groups, with statistically significant differences favoring the intervention group.

Jackson et al46 further found that quality of life (SF-36) was significantly improved in both of their intervention groups compared with the control group in both the physical and mental composite scores, with no statistically significant differences noted between the 2 intervention groups. None of the included studies reported any adverse events occurring during the trials. However, only one of the studies45 specifically indicated an absence of adverse events.

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Methodological Quality

One of the non-RCTs43 was found to have moderate quality, and one of the RCTs45 was found to have a low risk of bias. The remaining studies could be considered low quality or at a high risk of bias. Downs and Black checklist scores of the 3 non-RCTs ranged from 6 to 11. The critical items missing from all 3 non-RCTs were: adequate descriptions of the representativeness of participants, treatments, and settings; a lack of participant and provider blinding; a description of study compliance or adverse events; and adequate power calculations. The 2 included RCTs had 246 and 745 items with low risk of bias; common potential biases were a lack of blinding of participants and providers and nonreporting of treatment compliance. The overall quality of the available evidence was rated as low, as we judged future research to be highly likely to change our estimate of the effect.

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DISCUSSION

We found only a small number of studies focusing on the use of core stability exercise as a treatment for athletes with LBP, including only 2 RCTs. There was important heterogeneity among included studies and an overall low quality of evidence available. Most of the included studies reported statistically significant and clinically important improvements in pain intensity over time in the groups performing core stability exercises. Two RCTs, 1 with a low risk of bias, demonstrated statistically significant and clinically important differences in pain intensity and functional outcomes, favoring core stability exercise over conventional treatment45 and regular training.46 Differences in the studies included the ages of the athletes involved, the sports in which they participated, and the different forms of “core stability exercise” used as an intervention. This heterogeneity precluded meta-analysis. Furthermore, none of the studies reported long-term follow-up, and sample sizes were small.

Core stability exercises have received increasing scrutiny recently.29,47 One survey indicated that core stability exercises are the most frequently recommended form of exercise by Irish physical therapists.48 Previous systematic reviews and meta-analyses have demonstrated that core stability exercise programs can be effective for specific populations with LBP, particularly those with chronic LBP.21,23,24,30 The limited findings provided by the current review of athletes with LBP undergoing core stability exercise programs demonstrates conflicting findings in both within-group and between-group differences, particularly when considering clinically important differences in pain intensity and functional outcomes. That being said, the 3 studies that included athletes with chronic LBP42,45,46 generally reported statistically significant and clinically important within-group and/or between-group improvements in pain intensity for their core stability groups. However, only one of those studies45 on patients with chronic LBP was found to have a low risk of bias. The one study that specifically included athletes with acute LBP43 did not report statistically significant improvements in pain intensity over time for their core stability group. These findings are similar to what has been found for the general population.

Issues with muscular weakness, imbalance, and recruitment specific to the hip and/or core musculature have been implicated among many potential sources of LBP in athletes.49–53 Athletes with a history of LBP are also at increased risk for future LBP.54 Therefore, it seems plausible that core stability exercises would be a potentially suitable intervention to consider for athletes with LBP. Although core stability exercises may be useful in treating athletes with chronic LBP, it cannot be conclusively stated which form(s) of core stability exercise are most effective because the included studies varied.

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Strengths and Weaknesses

Among the strengths of this review were the searching of multiple databases and using reference searching, along with authors independently evaluating database search results and assessing the literature for quality and risk of bias, with a third author resolving differences. However, the relatively small number of studies that met the inclusion criteria and the overall low quality of included studies could lead to bias in the conclusions. In addition, the inclusion of nonrandomized comparative studies and uncontrolled studies in this review could potentially be a source of bias. Another limitation was that only articles in English were retrieved. However, as the search strategy was conducted in all languages, such cases should have been identified. It is also possible that there is publication bias with respect to the use of core stability exercises in athletes with LBP, particularly given the popularity of core stability exercises in the lay media and their use among the general population.

The heterogeneity of the included studies (eg, athlete characteristics, nature of the “core stability exercise” interventions) limits the interpretation of the findings of this review and their applicability in clinical practice. It is also acknowledged that some participants in studies evaluating core stability exercises for LBP in the general population may be athletes from different sports and at different levels of competition. However, such studies also include nonathletes and do not specifically analyze the results of athletes versus nonathletes.

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Future Research Directions

Further research is clearly needed on this topic. Researchers and clinicians need to determine whether core stability exercises should be used to treat low back injuries, prevent low back injuries and possible recurrences, or if they should be used for performance enhancement. Perhaps, the role of core stability exercises is a combination of the above. A consistent definition of what comprises a core stability exercise must be used in future research. This could be determined through a consensus study.

Higher-quality adequately powered RCTs are needed to determine which interventions have the greatest effect on athletes with LBP and should compare different forms of core stability exercise, both alone and in combination with other treatments (eg, manual therapies, biopsychosocial interventions, different forms of exercise therapy). The effects of core stability exercises in athletes with LBP of different durations (ie, acute, subacute, or chronic) across different age groups (youths, adults, seniors), from different sports, and at different levels of competition (recreational, amateur, professional), each need to be further evaluated. Continued use of the VAS as an outcome measure is advocated for future research, as well as some form of functional outcome, and a measure of disability due to back pain (eg, ODI). The use of standardized exercise protocols and outcome measurement in future research would be beneficial in allowing for meta-analyses to be performed.

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CONCLUSIONS

The quantity and quality of the evidence available on the use of core stability exercise as an intervention for athletes with LBP is low. The types of exercises evaluated in the included studies varied considerably as did study populations, which were small and saw only mixed results in terms of short-term pain intensity and disability. Pooling of data was not possible and the state of the evidence precludes conclusions from being drawn at this point. Further research on this topic is clearly needed and should include consistent definitions of both study populations and interventions.

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ACKNOWLEDGMENTS

The authors thank and acknowledge Anne Taylor-Vaisey of the Canadian Memorial Chiropractic College and Mary Chipanshi of the University of Regina for their assistance with formulating the search strategy and conducting the literature search.

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REFERENCES

1. Jonasson P, Halldin K, Karlsson J, et al.. Prevalence of joint-related pain in the extremities and spine in five groups of top athletes. Knee Surg Sports Traumatol Arthrosc. 2011;19:1540–1546.
2. Foss IS, Holme I, Bahr R. The prevalence of low back pain among former elite cross-country skiers, rowers, orienteerers, and nonathletes: a 10-year cohort study. Am J Sports Med. 2012;40:2610–2616.
3. Durall CJ, Udermann BE, Johansen DR, et al.. The effects of preseason trunk muscle training on low-back pain occurrence in women collegiate gymnasts. J Strength Cond Res. 2009;23:86–92.
4. Walker BF. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord. 2000;13:205–217.
5. Mogensen AM, Gausel AM, Wedderkopp N, et al.. Is active participation in specific sport activities linked with back pain? Scand J Med Sci Sports. 2007;17:680–686.
6. Hoskins W, Pollard H, Daff C, et al.. Low back pain status in elite and semi-elite Australian football codes: a cross-sectional survey of football (soccer), Australian rules, rugby league, rugby union and non-athletic controls. BMC Musculoskel Disord. 2009;10:38.
7. Gatt CJ, Hosea TM, Palumbo RC, et al.. Impact loading of the lumbar spine during football blocking. Am J Sports Med. 1993;25:317–321.
8. Reed JJ, Wadsworth LT. Lower back pain in golf: a review. Curr Sports Med Rep. 2010;9:57–59.
9. Ferdinands RED, Kersting U, Marshall RN. Three-dimensional lumbar segment kinetics of fast bowling in cricket. J Biomech. 2009;42:1616–1621.
10. Moorman CT, Johnson DC, Pavlov H, et al.. Hyperconcavity of the lumbar vertebral endplates in the elite football lineman. Am J Sports Med. 2004;32:1434–1439.
11. Paxton ES, Moorman CT, Chehab EL, et al.. Effect of hyperconcavity of the lumbar vertebral endplates on the playing careers of professional american football linemen. Am J Sports Med. 2010;38:2255–2258.
12. Ong A, Anderson J, Roche J. A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic Games. Br J Sports Med. 2003;37:263–266.
13. Hangai M, Kaneoka K, Hinotsu S, et al.. Lumbar intervertebral disk degeneration in athletes. Am J Sports Med. 2009;37:149–155.
14. Gerbino PG, D'Hemecourt PA. Does football cause an increase in degenerative disease of the lumbar spine? Curr Sports Med Rep. 2002;1:47–51.
15. Soler T, Calderón C. The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med. 2000;28:57–62.
16. Trainor TJ, Trainor MA. Etiology of low back pain in athletes. Curr Sports Med Rep. 2004;3:41–46.
17. Sakai T, Sairyo K, Suzue N, et al.. Incidence and etiology of lumbar spondylolysis: review of the literature. J Orthop Sci. 2010;15:281–288.
18. Johnson M, Ferreira M, Hush J. Lumbar vertebral stress injuries in fast bowlers: a review of prevalence and risk factors. Phys Ther Sport. 2012;13:45–52.
19. Hall S. Mechanical contribution to lumbar stress injuries in female gymnasts. Med Sci Sports Exerc. 1986;18:599–602.
20. Standaert CJ, Herring SA, Pratt TW. Rehabilitation of the athlete with low back pain. Curr Sports Med Rep. 2004;3:35–40.
21. Hayden J, Van Tulder M, Malmivaara A, et al.. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;CD000335.
22. Richardson C, Jull G, Hodges P, et al.. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain: Scientific Basis and Clinical Approach. Edinburgh, United Kingdom: Churchill Livingstone; 1999.
23. Bystrom M, Rasmussen-Barr E, Grooten WJA. Motor control exercises reduces pain and disability in chronic and recurrent low back pain. Spine. 2013;38:E350–E358.
24. Macedo L, Maher C, Latimer J, et al.. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther. 2009;89:9–25.
25. Akuthota V, Ferreiro A, Moore T, et al.. Core stability exercise principles. Curr Sports Med Rep. 2008;7:39–44.
26. Barr KP, Griggs M, Cadby T. Lumbar stabilization. Am J Phys Med Rehab. 2005;84:473–480.
27. Barr KP, Griggs M, Cadby T. Lumbar stabilization. Am J Phys Med Rehab. 2007;86:72–80.
28. McGill S, Grenier S, Kavcic N, et al.. Coordination of muscle activity to assure stability of the lumbar spine. J Electromyogr Kinesiol. 2003;13:353–359.
29. Standaert CJ, Herring S. Expert opinion and controversies in musculoskeletal and sports medicine: core stabilization as a treatment for low back pain. Arch Phys Med Rehabil. 2007;88:1734–1736.
30. Wang X, Zheng J, Yu Z, et al.. A meta-analysis of core stability exercise versus general exercise for chronic low back pain. PLoS One. 2012;7:e52082.
31. Moher D, Liberati A, Tetzlaff J, et al.. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097.
32. Higgins J, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.0.2. The Cochrane Collaboration; 2009. www.cochrane-handbook.org. Accessed October 1, 2012.
33. Furlan AD, Pennick V, Bombardier C, et al.. 2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine (Phila Pa 1976). 2009;34:1929–1941.
34. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52:377–384.
35. Stuber KJ, Smith DL. Chiropractic treatment of pregnancy-related low back pain: a systematic review of the evidence. J Manipulative Physiol Ther. 2008;31:447–454.
36. Ostelo RWJG, Deyo RA, Stratford P, et al.. Interpreting change scores for pain and functional status in low back pain. Spine. 2008;33:90–94.
37. Brozek JL, Akl EA, Alonso-Coello P, et al.. Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions. Allergy. 2009;64:669–677.
38. Marini M, Sgambati E, Barni E, et al.. Pain syndromes in competitive elite level female artistic gymnasts. Role of specific preventive-compensative activity. Ital J Anat Embryol. 2008;113:47–54.
39. Nigg BM, Davis E, Lindsay D, et al.. The effectiveness of an unstable sandal on low back pain and golf performance. Clin J Sport Med. 2009;19:464–470.
40. Dufek J, House A, Mangus B, et al.. Backward walking: a possible active exercise for low back pain reduction and enhanced function in athletes. J Exerc Physiol. 2011;14:17–26.
41. Perich D, Burnett A, O'Sullivan P, et al.. Low back pain in adolescent female rowers: a multi-dimensional intervention study. Knee Surg Sports Traumatol Arthrosc. 2011;19:20–29.
42. Ganzit GP, Chistotti L, Albertini G, et al.. Isokinetic testing of flexor and extensor muscles in athletes suffering from low back pain. J Sports Med Phys Fitness. 1998;38:330–336.
43. Harringe ML, Nordgren JS, Arvidsson I, et al.. Low back pain in young female gymnasts and the effect of specific segmental muscle control exercises of the lumbar spine: a prospective controlled intervention study. Knee Surg Sports Traumatol Arthrosc. 2007;15:1264–1271.
44. Hides JA, Stanton WR, McMahon S, et al.. Effect of stabilization training on multifidus muscle cross-sectional area among young elite cricketers with low back pain. J Orthop Sports Phys Ther. 2008;38:101–108.
45. Kumar S, Sharma V, Negi M. Efficacy of dynamic muscular stabilization techniques (DMST) over conventional techniques in rehabilitation of chronic low back pain. J Strength Cond Res. 2009;23:2651–2659.
46. Jackson JK, Shepherd TR, Kell RT. The influence of periodized resistance training on recreationally active males with chronic nonspecific low back pain. J Strength Cond Res. 2011;25:242–251.
47. Lederman E. The myth of core stability. J Bodyw Mov Ther. 2010;14:84–98.
48. Liddle SD, David Baxter G, Gracey JH. Physiotherapists' use of advice and exercise for the management of chronic low back pain: a national survey. Man Ther. 2009;14:189–196.
49. Nadler SF, Malanga GA, Feinberg JH, et al.. Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study. Am J Phys Med Rehabil. 2001;80:572–577.
50. Harris-Hayes M, Sahrmann SA, Dillen LRV. Relationship between the hip and low back pain in athletes who participate in rotation-related sports. J Sport Rehabil. 2009;18:60–75.
51. Hides J, Hughes B, Stanton W. Magnetic resonance imaging assessment of regional abdominal muscle function in elite AFL players with and without low back pain. Man Ther. 2011;16:279–284.
52. Iwai K, Nakazato K, Irie K, et al.. Trunk muscle strength and disability level of low back pain in collegiate wrestlers. Med Sci Sports Exerc. 2004;36:1296–1300.
53. Renkawitz T, Boluki D, Grifka J. The association of low back pain, neuromuscular imbalance, and trunk extension strength in athletes. Spine J. 2006;6:673–683.
54. Greene HS, Cholewicki J, Galloway MT, et al.. A history of low back injury is a risk factor for recurrent back injuries in varsity athletes. Am J Sports Med. 2001;29:795–800.
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Medline Search Strategy

  1. Athlete.
  2. Athletic performance.
  3. Athletic injuries.
  4. Sports.
  5. Sports injuries.
  6. 1 or 2 or 3 or 4 or 5.
  7. Low back pain.
  8. Lumbar vertebrae.
  9. Lumbosacral.
  10. Spine.
  11. Low back pain.
  12. Lower back pain.
  13. Lumbar pain.
  14. Backache.
  15. 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14.
  16. Exercise therapy.
  17. Resistance training.
  18. Physical therapy modalities.
  19. Isometric contraction.
  20. Abdominal muscles.
  21. Dynamic muscular stabilization techniques.
  22. Periodized resistance training.
  23. Periodized musculoskeletal rehabilitation.
  24. Trunk muscle strength.
  25. Resistance exercise.
  26. Segmental muscle control exercise.
  27. Lumbar extensor strengthening.
  28. Back strengthening.
  29. Lumbar strengthening.
  30. Spine rehabilitation.
  31. Core exercise.
  32. Core strength.
  33. Core stabilization.
  34. Isometric core exercise.
  35. 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34.
  36. 6 and 15 and 35.
Keywords:

low back pain; athletes; exercise therapy; core stability

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