The Effects Of Core Stabilization Exercise And Strengthening Exercise On Proprioception, Balance, Muscle Thickness And Pain Related Outcomes In Patients With Subacute Nonspecific Low Back Pain

A randomized controlled trial
Reviewed by: Zachary Stango, SPT; Bridget Collier, PT, DPT

With the majority of low back pain stemming from idiopathic origin, the condition commonly engulfs a large percentage of rehab cases. In individuals with low back pain, proprioception (aka, the awareness of one’s body position in space) plays a key role in posture and balance control, with decreased control likely contributing to these episodes of pain. Core stabilization exercises that include activation of deeper muscles like the transversus abdominis and lumbar multifidus are utilized as a form of therapeutic exercise to supply the spine with adequate stability. Strengthening exercises for the superficial trunk musculature also aid in the stability of the spine. The randomized control trial conducted by Hlaing et al. (2021) aimed to measure these two parameters, core stabilization and strengthening exercises, on the effects of the factors that are often lacking in individuals with subacute non-specific low back pain, namely: proprioception, balance, and muscle thickness.

The inclusion criteria for this trial consisted of individuals ages 20-50, with subacute nonspecific low back pain of 6-12 weeks, and pain of 3-7/10 on the Visual Analog Scale with a score of 19% or greater on the Modified Oswestry Disability Index. 36 individuals were evenly split into groups performing core stabilization exercises or strengthening exercises and completed these programs for 30 minutes, three times a week, for four weeks. For the participants in the core stabilization group, the muscles were isolated utilizing a drawing in maneuver, with a biofeedback device and manual palpation used to ensure successful contraction. The core stabilization group progressed throughout the weeks to include co-contractions of the transversus abdominis and lumbar multifidus with upper and lower body movements, advancing from sitting to supine to quadruped to ultimately a standing position. For the participants in the strengthening exercise group, the program consisted of progressing exercises centered around spinal flexion and extension to target the abdominal and back musculature respectively, while also working the oblique muscles with side-lying leg raises.

Follow up metrics were examined following the scheduled programs, and proprioception was measured through joint repositioning, with balance analyzed using the Romberg Test and muscle thickness calculated with ultrasound imaging. The results of this study overall demonstrated significant improvements in proprioception, balance, muscle thickness and reductions in pain within both experimental groups. Compared to the strengthening exercise group, the core stabilization group displayed superior improvements in proprioception, balance, and muscle thickness. The participants that underwent core stabilization also exhibited greater reductions in their fear of movement and functional disability scores compared to the strengthening group.

Clinical Bottom Line:

The results of this trial serve as evidence that the inclusion of exercises targeting deep abdominal and spinal muscles, like the transversus abdominis and lumbar multifidus, should not be neglected when treating individuals with subacute nonspecific low back pain. The addition of core stabilization exercises, compared to a sole focus on strength, can contribute to a more holistic rehab approach. Low back pain is often a debilitating condition contributing to fear avoidance and altered compensatory movements, and the transversus abdominis and lumbar multifidus can serve as potent protectors of allowing patients to return to their prior level of function with confidence in their body’s ability to thrive.


Hlaing SS, Puntumetakul R, Khine EE, Boucaut R. Effects of core stabilization exercise and strengthening exercise on proprioception, balance, muscle thickness and pain related outcomes in patients with subacute nonspecific low back pain: a randomized controlled trial. BMC Musculoskelet Disord. 2021;22(1):998. Published 2021 Nov 30. doi:10.1186/s12891-021-04858-6

Is Dual-Task Training Clinically Beneficial to Improve Balance and Executive Function in Community-Dwelling Older Adults with a History of Falls?

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Balance is most generally defined as the ability to properly maintain postural control and adapt to various environmental stimuli through the interaction of sensory, motor, and cognitive systems. The three components of balance comprise of the visual system, the vestibular system, and the proprioceptive system. Dysregulation in any of these three systems can result in an increased propensity for falling. It is known that imbalance commonly occurs under dual-task conditions among older adults since cognitive function decreases with aging.

Dual-task training refers to the ability to perform both cognitive tasks and physical activities simultaneously. Due to the fact that both cognitive function and physical function steadily decrease as we age, dual task performance can deteriorate, resulting in falls in older adults when they perform activities of daily living that require maintaining balance. Numerous evidence-based studies have examined the effects of dual-task training on improving balance and reducing fall risks in high-risk older adults, such as individuals with Parkinson’s disease or post-stroke. However, few studies have analyzed the impact of dual-task training on both static and dynamic balance in older adults. Therefore, the aim of this study was to investigate the effects of dual-task training on static balance, dynamic balance, and executive function in older adults with a history of falls.

58 older adults were selected from local senior centers and randomly assigned into either the experimental group or the control group. There were numerous inclusion criteria for these participants: over 65 years of age, experienced falls in the last six months, and those who ambulate independently without any assistive devices. All subjects carried out a 45 min training session, twice a week for 6 weeks, and they only received the training program which was assigned to each group.

In the control group (n=29 participants), subjects conducted the balance training program focusing on body stability, body stability combined with hand manipulation, body transport, and body transport combined with hand manipulation. In the experimental group (n=29 participants), subjects were instructed in dual-task training. These subjects in the experimental group practiced balance tasks while simultaneously conducting cognitive tasks, and were asked to maintain attention to both balance and cognitive tasks at all times. Subjects in both groups completed a total of 12 sessions.

There were numerous outcome measurements utilized in this study. The One Leg Standing Test (OLST) was utilized to assess static balance where a participant places their hands on their hips and raises one leg from the floor with their eyes closed. To assess dynamic balance, the Timed Up and Go (TUG) test was performed where a participant rises from a chair and makes a round trip of 3 meters to sit back in the chair. Lastly, executive function was examined through the Trail-Making Test (TMT-B) .

The findings of this study showed that subjects in the experimental group achieved greater improvements in both static and dynamic balance compared to subjects in the control group. Therefore, the results of this study may indicate that dual-task training might be more effective in improving balance than the more traditionally-utilized functional balance training. Older adults require more attentional resources to maintain balance to compensate for decreases in sensory integration, suggesting cognitive components contribute monumentally to maintaining balance.

Clinical Application:

Dual-task training is clinically beneficial to improving static and dynamic balance, as well as executive function in older adults with a history of falls. Additionally, executive function, or the ability to facilitate higher-level cognitive skills, should be considered a major component in balance training for older adults. Below is a graphic of the protocol for the group with dual-task training:


Park JH. Is Dual-Task Training Clinically Beneficial to Improve Balance and Executive Function in Community-Dwelling Older Adults with a History of Falls?. Int J Environ Res Public Health. 2022;19(16):10198.

When Should We Repair Partial-Thickness Rotator Cuff Tears? Outcome Comparison Between Immediate Surgical Repair Versus Delayed Repair After 6-Month Period of Nonsurgical Treatment

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Partial-thickness rotator cuff tears (PTRCTs) are very common shoulder-related musculoskeletal injuries, especially in the middle-aged patient population, that can detrimentally impact activities of daily living and result in increased pain levels or functional impairment. Generally, PTRCTs are more painful than full-thickness rotator cuff tears (FTRCTs) and account for a higher proportion of rotator cuff tears. However, many aspects concerning the most effective management of PTRCTs are still controversial in the available scientific literature. This controversy is due to the numerous intrinsic and extrinsic factors that contribute to an individual cuff lesion and prognosis of  PTRCTs for each patient.

The aim of this randomized controlled trial was to investigate the ideal timeline for surgical intervention for patients with PTRCTs. There is a very generalized concern that the size of a partial-thickness rotator cuff tear may increase over time for patients if surgical intervention is considerably delayed. Similarly, it is clearly established in the evidence-based literature that there is no spontaneous healing of PTRCTs without surgical treatment. Researchers in this clinical study were interested in whether immediate surgical treatment of PTRCTs would result in better outcomes compared with delayed surgical treatments after nonoperative treatment. These researchers hypothesized that 6 months of preoperative nonoperative treatment would result in better clinical outcomes than immediate surgical repair for PTRCTs.

78 total patients with PTRCTs were enrolled into this randomized controlled trial. Patients were included in the study if their proportion of torn tendon thickness was greater than 50% and experienced less than 3 months of symptom duration. These patients with PTRCTs were then allocated into two treatment groups through computer-generated randomization: an immediate arthroscopic rotator cuff repair surgery group within 1 week of diagnosis (Group 1), and a group that received 6 months of conservative, nonoperative treatment prior to surgery (Group 2). The non-operative treatment group included instructions on activity modification, NSAIDs, corticosteroid injections into the shoulder joint, and physical therapy.

Following the arthroscopic rotator cuff repair surgeries, the same standardized postoperative rehabilitation protocols were applied to both groups. Each patient wore an abduction brace for the shoulder for 1 month after the operation. Following one month post-operation, pulley exercises were then prescribed to increase forward flexion active range of motion of the shoulder. The patient could then be progressed to isometric exercises in all planes of shoulder motion once passive range of motion was restored to 90%. Outcome measures evaluated at 3 months, 6 months, 12 months, and 24 months included: ASES scores for overall shoulder functional ability, VAS scores for pain levels, and active range of motion in the shoulder (forward flexion, external rotation at side, external rotation at 90 degrees of abduction).

The results of the randomized controlled trial were that both groups showed significant improvements in terms of functional scores and pain VAS scores compared with the initial period. However, at 6 months postoperatively, the group 2 patients (6 months of nonoperative treatment) showed significantly lower pain VAS score and higher ASES Scores than group 1 patients (immediate rotator cuff repair surgery). There were no significant differences between the 2 groups in ROM or functional outcomes at the 24-month follow-up mark.

Clinical Application:

Both immediate surgical repair and delayed repair after nonoperative care were effective in improving clinical outcomes of patients with PTRCTs. Immediate surgical repair is not clinically crucial for the treatment of patients with PTRCTs and a trial of preoperative conservative management may be warranted for patients that have symptomatic PTRCTs.


Kim Y-S, Lee H-J, Kim J-H, Noh D-Y. When Should We Repair Partial-Thickness Rotator Cuff Tears? Outcome Comparison Between Immediate Surgical Repair Versus Delayed Repair After 6-Month Period of Nonsurgical Treatment. The American Journal of Sports Medicine. 2018;46(5):1091-1096.

Manual therapy versus therapeutic exercise in non-specific chronic neck pain: a randomized controlled trial

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Non-specific chronic neck pain is a prevalent musculoskeletal dysfunction commonly described as pain in the lateral or posterior aspect of the neck. Neck pain acquires the label of chronicity when the duration of painful symptoms last longer than 12 weeks. Non-specific chronic neck pain (NCNP) has generated a substantial socioeconomic burden, as the number of prevalent cases of neck pain worldwide was estimated to be 288.7 million in 2015. The recurrence, progression, and underlying mechanisms for non-specific chronic neck pain are not well understood in the available evidence-based literature. However, many clinicians have theorized that NCNP may be associated with a deficiency in the proprioceptive abilities of the neck muscles; these muscles play a decisive role in the cervical joint position and motor control of the head.

There have been numerous studies conducted to evaluate the clinical efficacy of manual therapy and therapeutic exercise on patients with non-specific chronic neck pain. However, few research articles have appraised the time of action along with duration of effects for both manual therapy and therapeutic exercise. Manual therapy is known to reduce inflammatory biomarkers and alter activity in the pain processing centers of the brain, whereas therapeutic exercise assists with proper motor pattern reorganization along with structural adaptations to increase muscular strength. The aim of this randomized controlled trial was to compare the effects of these two different treatments for patients with NCNP in different stages of follow-up appointments.

Inclusion criteria for the study required participants between the ages of 18 and 50, with current neck pain that has continued for the past 12 weeks. Participants could only receive their assigned treatment of either manual therapy or therapeutic exercise and were prohibited from combining their assigned treatments with pharmacological adjuncts. A total of 65 participants completed the randomized controlled trial with 22 participants in the manual therapy group, 23 participants in the therapeutic exercise group, and 20 participants in the control group (sham treatment). There were numerous major outcomes analyzed in this study: pain levels using the Visual Analog Scale (VAS), pain pressure threshold (PPT), and level of neck disability utilizing the Neck Disability Index (NDI).

The treatment for the manual therapy group consisted of high thrust manipulation to the upper thoracic spine, mobilization of the upper cervical spine, and providing gentle distraction force to inhibit overactive suboccipital muscles of the neck. The treatment for the therapeutic exercise group consisted of exercises that focused on increased motor recruitment of the deep cervical neck flexor muscles. This therapeutic exercise group then progressed to isometric co-contraction exercises of the deep and superficial neck flexors, finally ending with eccentric motor recruitment of necks flexors and extensors in the final stage of their protocol. Patients assigned to the control group received treatment 1 (manual therapy) or 2 (therapeutic exercise) after completing the study.

The results of this study showed clear clinical efficacy for the therapeutic exercise and manual therapy treatment groups in comparison to the control group for patients with non-specific chronic neck pain. The researchers found that the level of neck disability in patients, measured through the Neck Disability Index (NDI), was more immediately reduced in the therapeutic exercise group compared to the manual therapy group. However, the manual therapy group created a more immediate reduction in patient’s painful symptoms measured through the VAS pain scale and pain pressure threshold.

Clinical Application:

Therapeutic exercise may help to reduce cervical disability in the short term before manual therapy, whereas manual therapy may help reduce pain perception in the short term before therapeutic exercise. This trend should be taken into consideration when crafting a treatment plan for patients with NCNP. However, an evidence-based, multimodal approach combining manual therapy, therapeutic exercise, and pain education could be the best therapeutic weapon for subjects with nonspecific chronic neck pain.


Bernal-Utrera C, Gonzalez-Gerez JJ, Anarte-Lazo E, Rodriguez-Blanco C. Manual therapy versus therapeutic exercise in non-specific chronic neck pain: a randomized controlled trial. Trials. 2020;21(1):682. Published 2020 Jul 28. doi:10.1186/s13063-020-04610-w

Effect of dry needling on lumbar muscle stiffness in patients with low back pain: A double blind, randomized controlled trial using shear wave elastography

Reviewed by Jerome Thomas, SPT, Tyler Tice, PT, DPT, OCS, ATC

Dry needling is an innovative treatment technique utilized by various healthcare practitioners such as physical therapists, physicians, and chiropractors. Dry needling is implemented by inserting needles into painful areas of muscle perceived to have motor abnormalities in an attempt to restore normal muscle function and alleviate higher levels of pain. These painful areas of muscle are more commonly referred to as myofascial trigger points by clinicians.

There is a growing body of new evidence and research that reinforces the clinical effectiveness of dry needling for various musculoskeletal conditions such as low back pain. However, there have been limited studies that evaluate the effect of dry needling on soft tissue stiffness after its application. This randomized controlled trial utilized ultrasound shear-wave elastography (SWE), technology that quantifies soft tissue elasticity by sending sound waves into the desired soft tissue area. Vibrations move faster through the areas of soft tissue that are more stiff and less elastic. The primary aim of this study is to compare the effects of dry needling and sham dry needling (control group), on lumbar muscle stiffness in individuals with low back pain.

There were several outcomes assessed at the end of this randomized controlled trial: self-reported pain using the numerical pain rating scale (NPRS), LBP-related disability using the Oswestry Disability Index (ODI), self-reported changes using the Global Rating of Change, as well as lumbopelvic active range of motion. The participants in this study were currently experiencing low back pain between the ages of 18 and 65. Current low back pain for the participants was defined as pain between the 12th rib and the buttocks region as well as an ODI score of at least 10%.

Following the baseline evaluation and outcome assessment, 60 participants were randomized to either receive dry needling or sham dry needling. Therefore, there were 30 participants in the dry needling group and 30 participants in the sham treatment group. Treatment was performed by an experienced physical therapist trained in dry needling and blinded to all outcomes. Treatment was applied to a total of four sites on both the lumbar multifidi and erector spinae, muscles of the low back region. During each insertion of the needle, a ‘pistoning’ (in and out motion) technique was used in an attempt to elicit a local twitch response. Each participant was instructed to perform a double knee-to-chest maneuver 6 times for 5–10 seconds to alleviate residual soreness.

The results of the study showed that the resting erector spinae muscle stiffness was lower in individuals that received dry needling than in those that received sham dry needling 1 week after treatment. Additionally, individuals that received dry needling reported statistically larger overall improvements using the Global Rating of Change scale, as well as statistically significant improvements in pain levels utilizing the numerical pain rating scale (NPRS). No serious adverse events were reported throughout the course of this randomized controlled trial.

 Clinical Application:

Dry needling can be utilized as an effective intervention for individuals with low back pain to attenuate muscular stiffness in the low back region, as well as provide improvements in pain levels. Dry needling can be a useful intervention to help reduce the activity of myofascial trigger points, decrease hypersensitivity of taut bands in skeletal muscle, as well as restore normal muscle function during routine functional activities.


Koppenhaver SL, Weaver AM, Randall TL, et al. Effect of dry needling on lumbar muscle stiffness in patients with low back pain: A double blind, randomized controlled trial using shear wave elastography. J Man Manip Ther. 2022;30(3):154-164.

Targeted Treatment Protocol in Patellofemoral Pain: Does Treatment Designed According to Subgroups Improve Clinical Outcomes in Patients Unresponsive to Multimodal Treatment?

Reviewed by Jerome Thomas, SPT, Tyler Tice, PT, DPT, OCS, ATC

Patellofemoral pain syndrome (PFPS) is a chronic musculoskeletal condition characterized by persistent anterior knee pain. This condition is sometimes referred to as “runner’s knee” because it is common in individuals who participate in sports or recreational activities. However, patellofemoral pain syndrome can also occur in nonathletes as the increased pain levels and stiffness can make it difficult to climb up stairs, kneel down, and other activities of daily living.

Often times, a multimodal approach is utilized to treat individuals with PFPS. However, there is very little evidence to support the idea that the current multimodal approach for treatment of PFPS leads to successful clinical outcomes. A research study by Brown et al. on patients with PFPS, showed that only 46% of patients’ knees were pain-free at discharge. Based on the failures of the current multimodal treatment approach, there has been a strong recommendation from the International Patellofemoral Pain Research Retreats to clinically subgroup patients with PFPS and deliver targeted treatments. This prospective crossover intervention categorized patients with PFPS into 3 subgroups to assess whether targeted treatments would show clinical benefits over a multimodal approach.

The participants for this study were between the ages of 18 and 40, attending a physical therapy outpatient clinic at a university hospital with a clinical diagnosis of PFP. Various assessment tools were utilized to categorize the patients with PFPS: quadriceps and hip abductor muscle strength in the form of manual muscle tests, patella glide test, quadriceps length, gastrocnemius length, and the foot posture index. Based on these PFPS criteria, the participants were classified into 1 of 3 subgroups: strong, weak and tight, or weak and pronated feet.

All 61 patients in this crossover intervention study were given 6 weeks of multimodal treatment. The multimodal treatment included thermotherapy (heat application), transcutaneous electrical neural stimulation (TENS), stretching, as well as hip and knee strengthening. 21 patients responded positively to this treatment approach but 40 patients were non-responders to this approach. The 40 PFPS non-responders were then given an additional 6 weeks of targeted treatment based upon one of the three subgroups they were classified within. The intervention program for the “strong” subgroup was targeted at improving neuromuscular control and coordination ability using proprioceptive exercises. In the “weak and tight” subgroup, the exercise program consisted of closed kinetic chain (CKC) muscle strengthening and stretching and weight management advice. Lastly, the “weak and pronated foot” subgroup had an intervention program that included CKC strengthening exercises and foot orthoses.

Pain during activity measured using a visual analog scale (VAS) was the primary outcome measure of this study. The perception of recovery scale (PRS) was also utilized where patients rated themselves from “worse than ever” to “completely recovered” on a 7-point scale. The results of the study showed that 72.5% (29 patients) of the 40 PFPS non-responders demonstrated recovery after targeted treatment approaches. Recovery was measured through improved pain intensity (VAS) scores at rest and during activity, as well as significantly improved PRS scores. The findings of this intervention study suggest that targeted interventions based on subgroups provide a more effective treatment strategy for patients with PFPS.

Clinical Application:

Patients with PFPS who do not respond positively to the current multimodal treatment approach may benefit from a more targeted treatment. Targeted subgroups used to classify PFPS patients as “strong,” “weak and tight,” or “weak and pronated foot” provide a blueprint for targeted interventions that can improve clinical outcomes. Below is a graphic that outlines the targeted interventions for each subgroup:


Yosmaoğlu HB, Selfe J, Sonmezer E, et al. Targeted Treatment Protocol in Patellofemoral Pain: Does Treatment Designed According to Subgroups Improve Clinical Outcomes in Patients Unresponsive to Multimodal Treatment?. Sports Health. 2020;12(2):170-180. doi:10.1177/1941738119883272

Brown J. Physiotherapists knowledge of patellofemoral pain syndrome. Br J Ther Rehabil. 2000;7:346-353.