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Year : 2014  |  Volume : 7  |  Issue : 4  |  Page : 443-446  

Comparative study of muscle strengthening exercises for treatment of chronic low backache

1 Department of Orthopaedics, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
2 Department of Pathology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
3 Department of Orthopaedic Physiotherapy, Burdwan Institute of Medical and Life Sciences, Burdwan, West Bengal, India
4 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India

Date of Web Publication25-Jun-2014

Correspondence Address:
Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan - 713102, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-2870.135258

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Background: Low back pain is a major cause of musculoskeletal disability worldwide. Objectives: To study the outcomes of different muscle strengthening exercises in treatment of low back pain Materials and Methods: One hundred and twenty patients in the age group of 20-40 years with mechanical low back pain were randomly divided intotwo groups and instructed to perform two different types of exercises for three months (Mckenzie exercise andSwiss ball exercise). Patients were assessed by Visual Analogue Scale (VAS), Modified Schober Test (MST) for extension and Oswestry Disability Index (ODI), based on pain intensity levels, range of motion, functional disability before starting the exercise programmes and after 3 months of intervention. Results were analysed using Students T Test. Results: There was no significant difference in the pre-treatment session between the two groups. VAS and ODI Values were significantly lower in post-treatment sessions as compared to pre-treatment values in both Groups but MST Values in post-treatment sessions in Group practicing Mckenzie exercise showed significant decreases. Significant decrease in VAS, MST and ODI Valueswere found in subjects practising McKenzie exercise when comparison was done between the two groups after 3 months of treatment. Conclusion: McKenzie exercise and Swissball exercise in patients with mechanical Low back pain reduce pain intensity, increaserange of movementand decrease functional disability. McKenzie exercise seems to have higher efficacy as compared to Swissball exercise.

Keywords: Mechanical low backpain, muscle strengthening exercises

How to cite this article:
Ghosh S, Datta S, Nayak S, Chaudhuri A, Dhanasekaran P. Comparative study of muscle strengthening exercises for treatment of chronic low backache. Med J DY Patil Univ 2014;7:443-6

How to cite this URL:
Ghosh S, Datta S, Nayak S, Chaudhuri A, Dhanasekaran P. Comparative study of muscle strengthening exercises for treatment of chronic low backache. Med J DY Patil Univ [serial online] 2014 [cited 2023 Feb 6];7:443-6. Available from:

  Introduction Top

Low back pain (LBP)iscommon problem of the industrial world. [1],[2] Mechanical factors are major causes of LBP. Mechanical spinal pain due to mechanical deformation of soft tissues is classified into postural, dysfunctional and derangement syndromes. Excess flexion causes deformation in lumbar spines and progress with time irrespective of age. Eventually, supportive soft tissues succumb to stresses of poor sitting postures with sustained flexion. [1],[2],[3],[4]

Lumbar spine assumes fully flexed position while sitting. The function of supporting muscles of back during relaxation phase is carried out by ligamentous structures whose overstretching leads to mechanical deformation causing postural pain. [1],[3],[4] Patients with sole postural pain are usually underexercised; in agegroup of 30 yrs or below with sedentary occupations. [4],[5]

Spinal stabilizing systemcomprise ofvertebral column providing intrinsic stability;muscles providing dynamic stability and neural control unit evaluating and determining requirements for stability and coordinating muscle response. [1],[2] Physiotherapy strengthens deep abdominal core muscles supporting the spine. Unlike external lumbar support; core stability training act as active support throughout the day during all kinds of activities. [6],[7]

Bulging discs and narrow spinal canals occur in most people. Most subjects adapt perfectly well to these findings by staying fit and avoiding poor posture. If simple treatments are unsuccessful, additional tests, for example an M.R.I and more aggressive treatments like epidural injections or even microsurgery are performed. A variety of therapeutic treatmentspublished in the past include the McKenzie technique to allegedly force discs back into place, sauna, hydrotherapy, and core muscle strengthening exercises. Studies have shown that strengthening the core muscles in the body reduces the chance of back injury. [7],[8],[9]

The first use of the gym ball was done by Swiss therapists to help improve balance and equilibrium in children with cerebral palsy. They are safe, minimize the danger of injury, and help to activate proprioception, balance, and equilibrium control. Benefits of the gym ball include increased muscle activation, co-activation and co-contraction. [10],[11]

Low back pain is a major health problem with enormous economic and social costs. So the present study was conducted to investigate the approaches that would help to reduce pain and increase functional ability by adopting two different modes of exercise therapy i.e. McKenzie technique and Swiss ball therapy. There are only a very few studies comparing the two exercise modalities in a developing country like India, where economic loss is a great burden for the nation.

  Materials and Methods Top

This prospective study was conducted in a tertiary care hospital in West Bengalin a time period of one year after taking clearance from the institutional ethical committee and consent of the patient.

One hundred and twenty patients who had attended Orthopaedic outdoorwith LBP were included in this randomized cross sectional study anddivided into two groups: Group A and Group B (Age, Sex and BMI matched).Inclusion criteria: Subjects ofboth sexes presenting withLBP (during or after prolonged sitting or after performing any other activity) in age group of 20-40 years.

Exclusion criteria: Patients with gross musculoskeletal, neurologicaldisorder, pregnancy,cardiovascular and metabolic disorder, and on drugs that may alter test results were excluded.

After history taking and Clinical examination, randomization of sixty patients was done with odd number patients in Group A and evenin Group B. Average age of patients in Group A was 31 (7.79) years and in Group B was 29.73 (7.025) yrs. Assessment of pain was done by Visual Analogue scale (VAS), range of motion by Modified Schober Test (MST) for extension and Oswestry Disability Index (ODI) for functional disability. VAS, MST, ODI were estimated on first day prior to treatment and after 3 months of treatment in both groups.Visual Analogue scale (VAS): It consists of a 10 cm line, bounded by terminal anchors (e.g. pain as bad as it could be or no pain at all). The patient is allowed to mark the line relative to the intensity of pain. Scores can be between 0-10, where 0 is no pain at all and 10 where pain intensity is maximum. [12]

Modified Schober Test (MST) for extension: A point is marked between dimples of pelvis at the level of S 2. Two points, one 5 cm below and the other 10 cm above are marked and the distance between the two is measured. The patient is asked to extend spine to the maximum extent and the distance is remeasured and the difference is calculated. [12]

Oswestry Disability Index (ODI): ODI helps in assessing how LBP isaffecting daily lifeactivities including pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, travelling. Each item is scaled from 0-5 with higher values representing greater disability. ODI = Total score according to patient\ 50 × 100. Score: 0-20% (minimal disablity); 21-40% (moderate disablity); 41-60% (severe disablity); 61-80% (crippled); 81-100% (bed ridden). [12],[13] There was no difference in the above score values between the two groups prior to treatment.

Patients in Group A were asked to perform McKenzie exercise 10 times twice daily thrice a week for 3 months. The exercises included 1) Extension in lying with elbow flexed: Patient was asked to lie in prone position. Then supporting forearm with flexed elbows, patient was asked to lift the headwith chest off the ground for 5 seconds 2) Extension in lying with elbow extended: Elbows here were extended slowly from flexed positionand head, chest, upper abdomen lifted off the ground maintaining the position for 5 seconds. 3) Extension in standing: Patientswere asked to stand in erect posture keeping hands over both iliac crest and extendspine backward up to maximum limit without posterior tilting of pelvis, maintaining position for 5 seconds. [4],[5],[10]

Group B underwent Swiss ballexercise thrice a week for 3 months. Exercises performed in three sets of 10 repetitions holding each position for four seconds. 1) Sitting on ball: Patient was asked to sit at the centre of the ball with knees aligned with ankles, feet just wider than hip distance apart and firmly planted; then instructed to relax the shoulders letting body weight drop onthe ball, followed by sitting on ball for few minutes while breathing slowly. Patientswere asked to curl tailbone forward and let theball roll under followed by returning to neutral position. Then tailbone was to be pushed backward with backward rolling of ball and returned back to neutral position.Exercise repeated 10 times. 2) Back extension or Swan exercise:Patient was asked to kneelbehind the ball and climb on the ball droppingthe weight of the pelvis on the ball. Patient kept toes against wall arching back into extension. Thenpatient was instructed to lift the head, upper body just above the groundhorizontally. Patients were to inhale and exhale slowly. Exercise was repeated 10 times. [6],[7],[8],[9]

3) Bridging exercises:Patient was asked to lie supinewith the lower legs and feet secured over the ball and hands placed on floor along the body. Instructions were given to lift buttocks off the floor. Buttock and abdominal muscles were tightened andthe posture was maintained for few seconds. Exercise repeated 10 times. 4) Quadruped exercise: Swiss ball was positioned beneath abdomen with hip flexed to 90° and hands beneath shoulder joint of the patient. Subject was asked to flex arm, extend contralateral hip until both upper and lower limbs wereparallel to trunk and hold the position for a few seconds. Then contralateral limbs had to move and exercise repeated for 10 times. [6],[7],[8],[9]

Statistical analysis

Mean and SD values of all parameters were calculated. Paired Student's t test was done while comparing results of Pre-treatment and Post-treatment values. Un-Paired Student's t test was done while comparing Group A and Group B. P value < 0.05* was considered as statistically significant and < 0.01**highly significant.

  Results Top

There was no significant difference between the two groups in the pre treatment in respect of VAS, ODI and MST scores.VAS Values in post-treatment sessions were significantly decreasedin both Groupsas compared to pre-treatment values [Table 1]. Posttreatment values were significantly decreased in group A as compared to B [Table 2].
Table 1: Shows VAS values of group A and B

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Table 2: Shows post-treatment VAS values of group A and group B

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MST Values were significantly lower in post-treatment sessions than pre-treatment values and in Group A [Table 3]. Post treatment values were significantly decreased in group A as compared to B [Table 4].
Table 3: Shows MST values of group A and group B

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Table 4: Shows post-treatment MST values of group A and group B

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ODI values in were significantly lower in post-treatment sessions than pre-treatment values and in both Groups [Table 5]. Post treatment values were significantly decreased in group A as compared to B [Table 6].
Table 5: Shows ODI values of group A and group B

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Table 6: Shows post-treatment ODI values of group A and group B

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  Discussion Top

Back injury commonly occurs at a young age, however, when ageing reduces the ability of tissue to heal;back injury becomes a greater problem.Exercising techniquessignificantly reduce pain, increase range of movement, improve functional ability and can be assessed by VAS,MST,ODI scores in patients with mechanical LBP. [1],[2],[3],[10]

The present Study population included subjects with sedentary occupation. Intra group comparisons showed significant decrease in ODI, VAT scores during post-treatment assessment. Significant decrease in VAS, MST and ODI Values were found in subjects practising McKenzie exercise when comparison was done between the two groups after 3 months of treatment as compared to the other group.

Trunk extension programmes in different studies have shown improvement in some of core stability outcomes resulting in activating local and global muscle system creating stability around spine as well as decreasing pain. [9],[10]

Erector spinae and multifidus group of muscles are more strengthened with McKenzie than by swiss ballexecise. [9],[10] Trunk mobilisation in McKenzie exerciseresults in contraction of global trunk stabilising muscles. Local muscles are strengthened more in swiss ball exercise thus producing segmental stability. [6],[7],[8],[9],[10],[11],[13] Extension type of McKenzie exercise increases segmental stabilisation more. Improvement in both groups was achieved through reduction of stiffness of vertebral joints, increased lubrication of joints, optimal stretching of tightened soft tissues and segmental muscle co-contraction. [2],[3],[4],[6],[8],[9],[13] Range of movement was increased more in group A, as measured by MST for extension, pain reduction and disability reduction indicating McKenzie exercises as more beneficial.

Futures studies can be carried with larger samples in different groups of patients.Osteopathic manipulations, based on the premise that the neuromuscular system is vital in maintaining homeostasis may be considered in patients with nonspecific back pain that fails to improve with usual self caremeasures. [14]

  Conclusion Top

McKenzie exercise and Swissball exercise in patients with mechanicalLow back pain reduce pain intensity, increase range of movement, increase functional ability. McKenzie exercise seems to have higher efficacy as compared to Swissball exercise.

  References Top

1.Petrofsky JS, Batt J,Brown J, Stacey L,Bartelink T, Moine ML, et al. Improving the Outcomes after Back Injury by a Core Muscle Strengthening Program. J Appl Res 2008;8:62-75.  Back to cited text no. 1
2.Sterling M. A proposed new classification system for whiplash associated disorders - implications for assessment and management. Man Ther 2004;9:60-70.  Back to cited text no. 2
3.Liebenson C. McKenzie self-treatments for sciatica. J Bodyw Mov Ther 2005;9:40-2.   Back to cited text no. 3
4.Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med 2003;138:898-906.  Back to cited text no. 4
5.Chou R, Huffman LH. Non-pharmacologic therapies for acute and chronic low back pain: A review of evidence for an American pain Society/American college of physicians clinical practice guideline. Ann Intern Med 2007;147:492-504.  Back to cited text no. 5
6.Lehman GJ, Gordon T, Langley J, Pemrose P, Tregaskis S. Replacing a Swiss ball for an exercise bench causes variable changes in trunk muscle activity during upper limb strength exercise. Dyn Med2005;4:6.  Back to cited text no. 6
7.Merritt LG, Merritt CM. The gym ball as a chair for the back pain patient: A two case report .* Dr. Larry Merritt and Dr. Celynne Merritt are in private practice and may be contacted at: 1543 - 8 th Avenue, Prince George, British Columbia, V2L 3R3., Phone (250) 564-4202., Email [email protected] J Can Chiropr Assoc 2007;51:50-5.  Back to cited text no. 7
8.Mori A. Electromyographic activity of selected trunk muscles during stabilization exercises using a gym ball. Electromyogr Clin Neurophysiol 2004;44:57-64.  Back to cited text no. 8
9.Marshall PW, Murphy BA. Evaluation of functional and neuromuscular changes after exercise rehabilitation for low back pain using a Swiss ball: A pilot study. J Manipulative Physiol Ther 2006;29:550-60.  Back to cited text no. 9
10.Clare HA, Adams R, Maher CG. A systematic review of efficacy of McKenzie therapy for spinal pain. Aust J Physiother 2004;50:209-16.  Back to cited text no. 10
11.Cote AM, Durand MJ, Tousignant M, Poitras S. Physiotherapists and use of low back pain guidelines: A qualitative study of the barriers and facilitators. J Occup Rehabil 2009;19:94-105.  Back to cited text no. 11
12.Djavid GE, Mehrdad R, Ghasemi M, Zadeh HH, Manesh AS, Pouryaghoub G. In chronic low back pain, low level laser therapy is more beneficial than exercise alone in the long term: A randomized trial. Aust J Physiother 2007;53:155-60.  Back to cited text no. 12
13.Petrofsky JS, Laymon M, Lohman E, Berk L, Brains G. A new method for assessing bone pain in relation to range of motion for assessment of pain relieving modalities. J Appl Res 2011;11:1-9.  Back to cited text no. 13
14.Cole S, Reed J. When to consider osteopathic manipulation. J Fam Pract2010;59:E5-8.  Back to cited text no. 14


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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