The Effects of Stabilization Exercises Combined With Pelvic Floor Exercise in Women With Nonspecific Low Back Pain: A Randomized Clinical Study

Abstract

Objective

The purpose of this study was to investigate the effects of stabilization exercises (SEs) combined with pelvic floor muscle (PFM) exercises versus SE alone on pain intensity, functional disability, and static and dynamic endurance of trunk muscles in women with nonspecific low back pain (LBP).

Methods

A total of 48 women with nonspecific LBP (26-45 years) participated in the study. They were randomly allocated into 2 groups. Group A received SEs combined with PFM exercises and physical therapy modalities, and group B received the same intervention without PFM exercises for 6 successive weeks (3 times/wk). Pain intensity, functional disability, and static and dynamic trunk muscle endurance were measured before and after treatment program.

Results

After treatment, both groups revealed significant improvements in pain intensity and functional disability scores (P ˂ .05), and significant increases in static and dynamic endurance of trunk flexor and extensor muscles (P ˂ .05). Moreover, there was higher significance in group A compared to group B regarding pain intensity, functional disability scores, and static and dynamic endurance of trunk muscles (P ˂ .05).

Conclusion

In this study, the addition of PFM exercise to the SE and physical therapy modalities was more effective in reducing pain intensity, improving functional disability, and increasing the static and dynamic trunk muscle endurance in women with nonspecific LBP compared to SE alone.

Introduction

Nonspecific low back pain (LBP) is defined as LBP not attributed to perceptible, known specific pathology.¹ The review study of Green et al.² reported that nonspecific LBP is associated with many factors such as overweight/obesity,^3,4 low job satisfaction,⁵ poor work-related manual materials handling,^5,6 frequent bending and twisting,^5,6 driving heavy equipment that develop whole body vibration,^5,7 and increased age of workers.⁵

Women are more affected by the musculoskeletal system chronic pain conditions than men.⁸ Nonspecific LBP is common among people between ages 30 and 50 years,⁹ and crosswise different age groups.¹⁰ The sex differences in chronic pain recognition is attributed to the interactions among biological, psychological, and sociocultural factors.¹¹ Moreover, the perception of pain by women was higher than men, which explains the high pain sensitivity of women compared to men.¹² The fluctuations of menstrual cycle may explain the sex differences in pain sensitivity reported by younger adult women.¹³ Additional causes for LBP are the biologic response to pregnancy, childbearing, physical effort of child-rearing, and perimenopausal abdominal weight gain.¹⁴

The LBP prevalence ratio of female sex versus male sex was 1.13 for school-age group (6-19 years), 1.14 for young and middle-aged group (20-50 years), and 1.27 for elderly group (>50 years).¹⁰ When LBP lasts for several months, the body movement is restricted and muscle strength deteriorates. In chronic conditions, the cross-sectional area of paraspinal muscles is decreased, which leads to worsening of back pain, secondary injury, and pain recurring.¹⁵ The available evidence recommended that postural correction alone, back support, and ergonomic modification of shoe insoles do not eliminate LBP recurrence.¹⁶

Studies have reported that the exercise therapy has positive effects on pain and functional level in patients with nonspecific LBP.^17,18 Conventional exercise programs for nonspecific LBP consisting of strengthening and stretching of the abdominal and superficial back muscles have helpful effects on pain intensity and functional levels.^17,18,19 The conventional exercise programs were insufficient to stimulate the deepest layers of the back muscles, and unable to stabilize the pelvic that weaken the protective corset of lumbar muscle, which may prompt injury during exercise training.^19,20

Stabilization exercises may be adopted during designing a musculoskeletal rehabilitation for patients with LBP.²¹ The SE focuses on managing the trunk muscles, aiming to restore the deep intrinsic muscles of the lumbar spine and pelvis functions to coordinate the activities of the trunk deep and superficial muscles during daily living activities in patients with LBP.²² So, SE becomes a fundamental LBP approach to induce co-contraction and coordination of the spinal muscles.²³

The pelvic floor is made of muscles that connect the pelvis pubis anterior to the tailbone and ischial tuberosities posterior.²⁴ The pelvic floor muscles (PFMs) have a vital role in lumbar region stabilization through proper muscular activation.²⁵ This forms the abdominal cavity base and raises the intra-abdominal pressure during different daily tasks.²⁶ The abdominal muscles contract as a reaction to PFM contraction which contracts in response to both a “hollowing” and “bracing” abdominal order, and the abdominal muscles can activate PFM and vice versa.²⁷ The progression of LBP in women is associated with PFM dysfunction,^28,29 which can happen as a consequence of pain, weak movement patterns, and trauma during childbirth.²⁹ In a recent meta-analysis, it was suggested that adding PFM tracking to another exercise intervention may give a small benefit on pain severity in nonspecific LBP, but was based on low-quality evidence. The authors suggested that longer duration for an integrated core exercise program including PFM training may positively influence outcomes.³⁰

A contradiction exists in the literature regarding the effect of PFM exercise on chronic LBP in women. Rathi³¹ reported that the PFM exercise, combined with conventional treatment, was effective for improving pain intensity and functional disability compared to routine treatment alone. However, Mohseni-Bandpei et al³² concluded that the PFM exercise combined with conventional treatment was not superior to conventional treatment alone in patients with chronic LBP. Thus, the effects of PFM for chronic LBP are not clear.

As far as the authors are aware, there is a lack of reports about the results of PFM exercise when added to SE. Therefore, the purpose of this study was to explore the effect of SE combined with PFM exercise in women with nonspecific LBP compared to SE alone. The current study hypothesized that the addition of PFM exercise to SE and physical therapy modalities would reduce pain and improve functional disability and static and dynamic trunk muscle endurance.

Methods

Design

This randomized clinical study that enrolled women with LBP (single-blind) was conducted at the physical therapy clinic of Faculty of Physical Therapy, Cairo University, from December 2018 to June 2019.

Participants

Women were recruited if they were married (the prevalence of LBP is high in married women),³³ aged between 26 and 45 years old, with nonspecific LBP for at least 3 months,¹ and with mild or moderate functional disability based on the Oswestry Disability questionnaire.³⁴ The participants’ demographic characteristics are presented in Table 1.

Table 1.

Participants’ Demographic Characteristics

Groups	Group A, n = 21	Group B, n = 22	P value
Age, y	36.71 ± 6.17	38.14 ± 5.89	.443
Height, cm	164.38 ± 6.12	161.86 ± 5.19	.153
Weight, kg	74.81 ± 5.45	72.64 ± 5.86	.252
Body mass index	22.74 ± 1.59	22.42 ± 1.39	.483

Data are presented as mean ± SD. P > .05 means nonsignificant difference.

Exclusion criteria were incessant pain more than 8 based on a Numeric Pain Scale (NPS); symptoms of nerve root compression; stress urinary incontinence; obesity; pregnancy or postpartum LBP; pelvic girdle pain; unwillingness to do exercises; previous participation in any structured PFM training program; and specific musculoskeletal conditions as ankylosing spondylitis, fractures, spondylolysis, spinal stenosis, spondylolisthesis, neoplasm, sacroiliac joint disorders, osteoporosis, or previous pelvic or spinal surgeries and systemic diseases.

This study was conducted in accordance with Declaration of Helsinki ethical principles and was approved by research local ethics committee (approval no. P.T.REC/012/001925). Moreover, this study was clinically registered by the Pan African Clinical Trial Registry (PACTR201811706770691). The female volunteers were enrolled from the physical therapy clinic of faculty of physical therapy and signed an informed consent to participate in this study. They were randomly assigned by an independent researcher into group A, which received SE combined with PFM exercises and physical therapy modalities, and group B, which received the same intervention without PFM exercises.

By using random numbers of a computer-generated table, simple randomization was conducted by a statistician not involved in participant recruitment. During the randomization process, no blocking or stratification was performed. There were 76 female patients who were initially screened for eligibility; 28 out of them did not meet the inclusion criteria or were unwilling to participate in the study. The remaining 48 participants were randomized into 2 groups (n = 24/group). Figure 1 shows the recruitment and treatment allocations of the participants.

Fig 1.

Study flowchart.

The pre and post values of outcome measures were assessed by the same independent, experienced physical therapist not working at the rehabilitation center. Moreover, the statistician was unaware of the group allocation until data analyses were complete. They were blinded to treatment procedure and had no contact with participants. After 6 weeks of intervention, the measured outcomes were accessible for 21 of 24 patients in group A (2 women discontinued intervention and 1 woman did attend the post test), and 22 of 24 in group B (1 woman discontinued intervention and 1 woman did attend the post test).

Treatment

From a lying position, the spinal segmental SE started with training the participating women how to combine both the isometric contraction of transversus abdominis and multifidus muscles and how to maintain a proper contractions while doing simple movements. This combined contraction of the stabilizing muscles progressed from lying into kneeling, sitting, and standing positions.35, 36, 37 The participants were requested to keep their pelvic girdle and trunk muscles inactive during the exercises. The program consisted of different exercise sets: bridging exercises; pelvic elevation, curl-ups exercises; abdominal training, cat-camel exercises; mixed extension/flexion stretch of the spinal column, and hook-lying exercises; posterior pelvic inclination.^38,39 Each exercise was performed 20 repetitions with 15 seconds’ hold. The whole exercise set was repeated twice with 3 minutes rest in between.⁴⁰

For the pelvic floor muscle exercise program, while lying down with knees apart, the participants were requested to imagine they were attempting to prevent themselves from passing wind simultaneously as if they are attempting to stop passing urine and slowly press on and elevate muscles. They were instructed to avoid squeezing their legs together, pulling in their stomach, holding their breath or tightening their buttocks to ensure that only their PFM are working.⁴¹ This exercise consisted of 6 seconds contraction of the PFM followed by 6 seconds rest, resulting in 5 contraction cycles/min. Over the 6-week treatment period, the number of contraction cycles was increased; first week (25 cycles/d, 5 minutes total); second week (50 cycles/d, 10 minutes total); third week (75 cycles/d, 15 minutes total); fourth to sixth weeks (100 cycles/d, 20 minutes total).⁴²

Physical therapy modalities consisted of 20 minutes infrared irradiation 40 cm away from the low back region (R 125, 250 watts, Philips), followed by 30 minutes of conventional transcutaneous electrical nerve stimulation (TENS) that was applied at a frequency of 80 Hz with 10 to 30 mA intensity by using surface electrodes (5 × 5 cm each) that were placed over the painful area in the lumbar spine.⁴³ The Intelect Advanced device (REF2773MS, Chattanooga, Mexico) was used to deliver transcutaneous electrical nerve stimulation. Its intensity was set to generate a tingling sensation just about 2 to 3 times the sensory threshold of the patients. Finally, 5 minutes of continuous ultrasound was applied with 1 MHz, and 1.2 W/cm² intensity by using Metron Accusonic Plus device (Metron Medical Australia Pty Ltd).⁴⁴

The intervention duration for both groups was 6 weeks. The physical therapy modalities were applied 3 times/week. The SE and PFM exercise were performed daily 3 times/wk supervised by the same registered physical therapist for both groups. In the other days, all participants were recommended to carry out the exercises as a home exercise program.

Outcome Measurements

The primary outcome was pain intensity, which was evaluated by using the NPS (0 corresponded to no pain and 10 corresponded to the worst pain possible), which was the most precise, replicable, and valid measure used to assess the pain intensity.45, 46, 47 The participants were asked to determine the pain severity by placing a mark on the line with severe pain being the worst pain.

The secondary outcomes included functional disability and trunk muscle endurance: The functional disability was assessed by Oswestry Disability Index (ODI) score.⁴⁸ Each part scored from 0 to 5 and the final score was declared in the percentage form: 0-20, minimal disability; 21-40, moderate disability; 41-60, severe disability; 60-80, crippled; 81-100, bedridden. This questionnaire is one of the most useful instruments in evaluating the functional status of patients, and its reliability has been confirmed by different studies.^49,50

The trunk muscle endurance included static and dynamic muscle endurance: The static muscle endurance was assessed by time length that the participant was able to sustain without upper body support in prone (extension) and supine positions (flexion), and the dynamic muscle endurance was assessed by the number of supine trunk flexions (sit-ups) and prone trunk extensions achieved in 1 minute.⁵¹ These endurance tests were considered reliable tools for assessment of trunk muscles.⁵²

Regarding the trunk extensor static endurance: The woman was in the prone position on the examination table with the upper edge of the iliac crests located on the upper edge of the table. The pelvis, knees, and ankles were fixed to the table by 3 straps, and arms were bent to the chest. The woman was asked to isometrically maintain the upper body in a horizontal position. A chair was placed in front to support her by holding it with hands in case of inability to keep the position. For the assessment of the trunk flexor static endurance: The woman was lying on a well-padded smooth surface with hip and knees flexed, both at 90° degrees with the arms crossed over the chest. Then, she was asked to raise the trunk in a smooth motion, keeping the position as much as possible.⁵³ The dynamic endurance tests were conducted from the same positions.

Statistical Analysis

G Power software was used to calculate the sample size, which was determined as 30 participants in both groups according to an alpha = 0.05, power = 0.80, and effect size = 1.1. Thus, the suggested sample size of 48 participants was more than enough to conduct the current study. The effect size was estimated in accordance with the study of Mohseni-Bandpei et al,³² which was chosen owing to its similar methodological design (ie, blinded randomized controlled).

The SPSS for Windows version 16.0 (SPSS, Inc, Chicago, IL) was used to analyze the collected data. Before the final statistical analysis, the test of homogeneity and normality revealed that the data were normally distributed (P > .05). This test was essential before conducting the parametric data analysis. The significant differences in the mean values of age, weight, height, or body mass index (BMI) between both groups were investigated by using the independent t test. The differences between NPS, ODI, and trunk muscle endurance of both groups were tested by using the 2-way mixed analysis of variance. The level of significance (P < .05) was considered to be statistically significant with 95% CIs.

Results

Table 1 showed that there was no significant difference between both groups in age, height, weight, and body mass index (P = .443, .153, .252, .483, respectively). Descriptive statistics of the NPS, ODI scores, and static and dynamic endurance of the trunk muscles before and after intervention are shown in Table 2.

Table 2.

Descriptive Statistics of Visual Analog Scale, Oswestry Disability Index, and Trunk Muscle Endurance Before and After Intervention

Variables		Group A, n = 21	Group B, n = 22
Numeric pain scale	Pre	3.14 ± 1.44	3.32 ± 1.31
	Post	2.02 ± 1.20	2.84 ± 1.26
Oswestry Disability Index	Pre	28.76 ± 10.05	30.45 ± 10.75
	Post	18.52 ± 8.27	24.73 ± 9.91
Flexion static endurance, s	Pre	36.05 ± 14.60	38.32 ± 14.58
	Post	54.05 ± 13.08	45.27 ± 14.85
Extension static endurance, s	Pre	43.57 ± 11.89	45.86 ± 12.35
	Post	62.62 ± 9.87	55.23 ± 12.55
Flexion dynamic endurance, no.	Pre	32.97 ± 13.32	29.86 ± 6.12
	Post	49.86 ± 11.21	43.64 ± 6.65
Extension dynamic endurance, no.	Pre	15.67 ± 6.95	14.41 ± 6.01
	Post	23.86 ± 6.85	19.27 ± 5.63

Data are presented as mean ± SD.

In general, there was no significant difference in between-participant effect (groups; F = 1.22, P = .320), and significant difference within- participant effect (time; F = 7.78, P = .001) and interaction effect (time*group; F = 67.01, P = .001). Subsequently, multiple pairwise comparison tests were conducted to identify the source of significance regarding group interactions (treatment versus control) and time (pre versus post) factors.

The pre values of the NPS and ODI of both groups were not significantly different (P = .679, .597, respectively). The pre values of both groups were significantly higher than their post values (P = .001). The post values of group A were significantly lower than group B (P = .035, .032, respectively), as illustrated in Table 3.

Table 3.

2-Way ANOVA of Between-Participant and Within-Participant Effects of Visual Analog Scale, Oswestry Disability Index, and Trunk Muscles Endurance Before and After Intervention

Variables		Group A, n = 21X	Group B, n = 22	95% CI for Difference			Pre	Post		95% CI for Difference
		P value		Lower bound	Upper bound		P value		Lower bound		Upper bound
Numeric Pain Scale	Pre	.679		–1.02	0.67	Group A, n = 21	.001a		0.93		1.31
	Post	.035a		–1.57	– 0.06	Group B, n = 22	.001a		0.29		0.66
Oswestry Disability Index	Pre	.597		–8.11	4.72	Group A, n = 21	.001a		8.91		11.57
	Post	.032a		–11.84	–0.56	Group B, n = 22	.001a		4.43		7.03
Flexion static endurance, s	Pre	.951		–9.13	8.59	Group A, n = 21	.001a		–19.29		–16.71
	Post	.047a		0.14	17.41	Group B, n = 22	.001a		–10.21		–7.69
Extension static endurance, s	Pre	.539		–9.76	5.18	Group A, n = 21	.001a		–20.39		–17.71
	Post	.038a		0.42	14.37	Group B, n = 22	.001a		–10.68		–8.05
Flexion dynamic endurance, no.	Pre	.377		–3.53	9.14	Group A, n = 21	.001a		–18.93		–15.46
	Post	.032a		0.58	11.87	Group B, n = 22	.001a		–15.47		–12.08
Extension dynamic endurance, no.	Pre	.529		–2.74	5.26	Group A, n = 21	.001a		–8.53		–7.86
	Post	.021a		0.73	8.44	Group B, n = 22	.001a		–5.19		–4.54

ANOVA, analysis of variance.

^aSignificant difference (P < .05).

Regarding the trunk flexors and extensors static endurance, the pre values of both groups were not significantly different (P = .951, .539, respectively). The pre values of both groups were significantly lower than their post values (P = .001). The post values of the trunk flexors and extensors of group A were significantly higher than group B (P = .047, .038, respectively). For the trunk flexors and extensors dynamic endurance, the pre values of both groups were not significantly different (P = .377, .529, respectively). The pre values of both groups were significantly lower than their post values (P = .001). The post values of the trunk flexors and extensors of group A were significantly higher than group B (P = .032, .021, respectively), as shown in Table 3. There were no serious adverse effects or troubles recorded in both groups.

Discussion

The results of this study demonstrated that adding PFM exercise to SE and physical therapy modalities reduced pain and improved functional disability and static and dynamic trunk muscle endurance. The previous studies^25,38,44 examined the effect of PFM exercise on LBP have used samples of the 2 sexes with LBP. However, Wáng et al.¹⁰ reported that nonspecific LBP is commonly occurring in women more than men that could be clarified by hormonal causes related to sex differences. So, the significance of the current study is emphasized by selecting female sex only to participate in it.

The pain severity and functional disability scores of both groups have been improved, which may be attributed to the positive effects of the electrotherapeutic modalities on pain and functional disability in patients with LBP.^54,55 Moreover, SE is more effective in reducing pain severity than routine physical therapy exercises in participants with nonspecific LBP.⁵⁶ Also, SE concentrates on activation of the deep trunk muscles, which is more effective in alleviation of nonspecific LBP effects.⁵⁷

Furthermore, the improvement of group A was higher than group B, which may be caused by the PFM exercise mechanical effect, as it properly activates muscles responsible for lumbar stabilization.²⁵ The PFM is considered part of the muscular stability system of the spine that works as a corset surrounding the spine and abdomen in a synergic manner.⁵⁸ In the same context, Hodges et al⁵⁹ reported that the PFM contributes to trunk stability, which can be explained by its feedforward activation in response to trunk perturbation, resulting from rapid arm movement.

The findings of Malhotra and Chahal⁶⁰ support the positive effect of addition of PFM exercise to routine physical therapy exercises in women with nonspecific LBP, despite the difference in criteria of samples choice, as their participants were postpartum. They reported that the PFM exercise combined with abdominal exercise and routine treatment provide significant improvements in pain and disability, compared to spinal hyperextensions combined with abdominal muscle strengthening exercises in women with postpartum LBP.

The improvement of group A agreed with the findings of Bi et al,⁴⁴ who evaluated patients with nonspecific LBP after PFM exercise training. Their control group was treated with electrotherapeutic modalities and lumbar strengthening exercises, whereas the intervention group received the same treatment combined with PFM exercises for 24 weeks. They found a significant improvement in pain intensity and functional disability scores in the intervention group compared to the control group. Although the results of the present study were compatible with the findings of Bi et al,⁴⁴ they reported a significant improvement in strength and endurance of trunk flexor and extensor muscles of the intervention and control groups with no significant differences between groups. This could be explained by the fact that the lumbar strengthening exercise adopted by Bi et al⁴⁴ was limited to few repetitions of leg elevation and chest elevation from prone position and bridging exercises from a supine position, while the present study applied a full program of SE.

The present findings are inconsistent with Ghaderi et al,⁶¹ who found a low significant improvement in pain intensity and functional disability in patients who received 12 weeks of routine physical therapy treatment and others who received the same treatment in addition to PFM exercise, without significant difference between groups. Their participants had stress urinary incontinence, which has a negative impact on quality of life in social, psychological, and physical activities. This may explain the disagreement with the current results.⁶²

Few studies^32,37 showed that the combination of conventional physical therapy and PFM exercise was not superior to conventional treatment alone in patients with nonspecific LBP. The difference in PFM exercise intensity and repetitions, a fundamental component of the current study, may be the reason for this contradiction with the present findings.³² Another reason for this contradiction could be the small sample size³² and heterogeneity of the sample (subacute and chronic LBP).³⁷

The improvement of trunk endurance was supported by the recent findings of Suh et al,⁶³ who found that lumbar SE and walking exercise were equally effective in treating patients with LBP and superior than the flexibility exercise, not only for relieving pain but also through improving endurance of trunk muscles. However, their participants were of both sexes and older than those of the present study. They explained their findings by the ability of SE to reduce pain and improve the physical endurance through improving the neuromuscular control of back muscles, which maintains the dynamic trunk stability.⁶⁴

Finally, few studies have investigated the association between PFM training and back muscle strength or endurance in patients with LBP. So, the current study was the first research work that illustrated the SE combined with PFM exercise improved the back muscle endurance more than SE alone in women with nonspecific LBP. These results concur with Ghaderi et al,⁶¹ who found that SE focusing on PFM improved the strength of transversus abdominis muscle in women with nonspecific LBP. This may be explained by the coactivation work pattern of PFM and the abdominal muscles.²⁷ The improvement of back muscle strength coincides with the findings, which reported that in young cricketers LBP is associated with multifidus muscle weakness.⁶⁵ In addition, there was an association between nonspecific LBP and reduction of trunk flexor and extensor endurance in collegiate soccer players.⁶⁶ Furthermore, the cross-sectional area of the multifidus muscle improved after the stabilization training program focused on PFM, combined with the training of multifidus and transversus abdominis muscles,⁶⁵ which was concomitant with the decrease in pain intensity.

Clinical Applications

Based on the findings in this study, it is suggested that clinicians consider PFM exercise during designing a rehabilitation program for women with nonspecific LBP that may enhance their life quality and increase work productivity.

Limitations

First, only a female population with nonspecific LBP was included in this study. So, generalization of findings in patients with specific LBP is not possible. Secondly, the participants of the current study were middle-age women. Hence, with the prevalence of LBP increasing with age,¹⁰ it is recommended to conduct this study on other age groups, especially elderly women. Third, the workplace of the participants was not considered during the sample selection, which may affect the current results. So, work environment, job insecurity, long working hours in addition to wearing heels, and frequency and type of sports activities should be considered by healthcare practitioners. Finally, because the exercise program was semi-supervised, the compliance of the home exercise program was not assured. However, the participants were seen at least 3 times/wk to confirm that.

Long-term studies with follow up will be required in the future before generalization to wider patient groups. More research studies evaluating the effects of PFM exercises in addition to SE on muscle activity, thickness, and strength of PFM in women with LBP, associated with pelvic floor dysfunction, should be run to determine its effectiveness for those patients.

Conclusion

This study revealed that PFM exercise combined with SE and physical therapy modalities reduced pain intensity, improved functional disability, and increased trunk flexor and extensor static and dynamic endurance in women with nonspecific LBP.

Acknowledgements

We thank Dr Maher A. Mahdi, associate professor, English Department, Helwan University, Egypt for his help with English language editing and revision of this article.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): A.A.A.

Design (planned the methods to generate the results): A.A.A., O.R.A.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): A.A.A., A.H.D.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): A.A.A., O.R.A., A.H.D., H.M.E.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): A.A.A., O.R.A.

Literature search (performed the literature search): A.H.D., H.M.E.

Writing (responsible for writing a substantive part of the manuscript): O.R.A., A.H.D.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): A.A.A., O.R.A., A.H.D., H.M.E.

Practical Applications.

• •Stabilization exercise combined with pelvic floor exercise reduced pain and improved functional disability in women with LBP.
• •Stabilization exercises in addition to pelvic floor exercise was more effective in improving the static and dynamic endurance of the trunk compared to stabilization exercise alone.
• •Long-term studies with follow-up will be required in the future before generalization to wider patient groups.

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