medicina

Article
Effects of Gluteal Muscle Strengthening Exercise-Based Core
Stabilization Training on Pain and Quality of Life in Patients
with Chronic Low Back Pain
Seung-Eon Ahn 1 , Mi-Young Lee 2 and Byoung-Hee Lee 2, *

1 Graduate School of Physical Therapy, Sahmyook University, Seoul 01795, Republic of Korea;
[email protected]
2 Department of Physical Therapy, Sahmyook University, Seoul 01795, Republic of Korea; [email protected]
* Correspondence: [email protected]; Tel.: +82-2-3399-1634

Abstract: Background: The World Health Organization reports that back pain is a major cause of
disorder worldwide. It is the most common musculoskeletal disorder with limited pain, muscle
tension, and stiffness, and 70–80% of all individuals experience it once in their lifetime, with higher
prevalence in women than in men. This study aimed to investigate the effects of gluteal muscle
strengthening exercise- based core stabilization training (GSE-based CST) on pain, function, fear-
avoidance patterns, and quality of life in patients with chronic back pain. Methods: This study
included 34 patients with non-specific chronic low back pain. Seventeen individuals each were
included in GSE-based CST and control groups. The GSE-based CST group performed GSE and CST
for 15 min, three times a week for four weeks, and the control group performed CST for 30 min a
day, three times a week for four weeks. The numeric pain rating scale was used to evaluate pain
before and after treatment, Roland–Morris disability questionnaire was used to evaluate function,
fear-avoidance beliefs questionnaire was used to evaluate fear-avoidance patterns, and quality of
life was measured using the short form-36. Results: In this study, pain, function, and fear-avoidance
pattern decreased significantly in both groups (All p < 0.05). During the evaluation of quality of
life, both groups showed significant increase in physical and mental factors (p < 0.05). There were
significant differences in pain and quality of life (p < 0.05) between the GSE-based CST and control
Citation: Ahn, S.-E.; Lee, M.-Y.; Lee,
groups. Conclusions: Therefore, GSE-based CST can be used as a basis for effective intervention to
B.-H. Effects of Gluteal Muscle
Strengthening Exercise-Based Core
enhance pain, function, fear-avoidance patterns, and quality of life, emphasizing the need for gluteal
Stabilization Training on Pain and muscle strengthening exercises in patients with non-specific chronic back pain in the future.
Quality of Life in Patients with
Chronic Low Back Pain. Medicina Keywords: hip; low back pain; pain; function; strength exercise
2024, 60, 849. https://doi.org/
10.3390/medicina60060849

Academic Editor: Jan Bilski

1. Introduction
Received: 2 April 2024 Low back pain is the most common musculoskeletal disorder and the leading cause
Revised: 2 May 2024 of disorder. Between 70–85% of individuals experience low back pain at least once in
Accepted: 17 May 2024
their lifetime, with the highest prevalence occurring between the ages of 40–69 years. The
Published: 23 May 2024
annual prevalence rate of low back pain is between 15–45%, with a higher prevalence in
women than in men [1,2]. Many adults experience low back pain, but 60–90% of them
cannot find a specific cause [3]. Low back pain is mostly non-specific and mechanical in
Copyright: © 2024 by the authors.
nature. Non-specific low back pain often occurs spontaneously, and typically resolves
Licensee MDPI, Basel, Switzerland.
within 4–6 weeks [4]. Specific causes for back pain, such as infections, tumors, osteoporosis,
This article is an open access article spondyloarthropathies, and trauma, actually represent a minority of such pain syndromes,
distributed under the terms and qualifying for specific therapeutic approaches [5]. Specific causes of back pain are some de-
conditions of the Creative Commons generative conditions, inflammatory conditions, infective and neoplastic causes, metabolic
Attribution (CC BY) license (https:// bone disease, referred pain, psychogenic pain, trauma, and congenital disorders [6].
creativecommons.org/licenses/by/ Chronic low back pain is attributed to multiple factors, including delayed or reduced
4.0/). activation of the lumbar multifidus and transversus abdominis muscles during walking

Medicina 2024, 60, 849. https://doi.org/10.3390/medicina60060849 https://www.mdpi.com/journal/medicina

Medicina 2024, 60, 849 2 of 13

or limb movement, and diminished physiological activation of the transversus abdominis.

Muscle dysfunction can lead to loss of lumbar support, increasing stress on the surrounding
joints and ligaments of the lumbar spine [7]. Chronic low back pain significantly increases
the risk of comorbid conditions, including musculoskeletal, neurological, and psycholog-
ical issues [8]; furthermore, chronic low back pain significantly impacts quality of life,
affecting various aspects, including physical and psychological well-being. Individuals
with chronic low back pain experience a significant decrease in their quality of life across
all dimensions [9,10].
The treatment of patients with low back pain varies, depending on the classifica-
tion of the patient (specific versus non-specific) and duration of symptoms (acute versus
chronic) [11], and typically, exercise therapy targeting the transversus abdominis, lumbar
multifidus, and pelvic floor muscles is employed [12].
Core stability is the ability to control the position and movement of the trunk over
the pelvis, enabling optimal production, transfer, and control of force and motion during
integrated movement activities. Core muscle activity is understood as a pre-programmed
integration of local single-joint muscles and multi-joint muscles to provide stability and
generate movement [13]. The purpose of core stability exercises is to restore normal
muscle function to prevent shear forces that can induce segmental stiffness and lumbar
spine instability, enhancing pelvic region neuromuscular control, and reducing lumbar
injury [14].
Whether hip abductor and external rotator muscle exercises increase the lateral vector
force of the patella warrants clarification. These exercises could incorporate hip abductor
and external rotator muscle training activities and also induce vastus lateralis muscle
activity through muscular cocontraction. Selective gluteus medius muscle activation was
induced during the hip abduction and external rotation movements, accompanied by an
increase in vastus lateralis muscle activation [15].
When considering the influence of muscles that contribute to low back pain, the gluteal
muscles play a crucial role as they transmit force from the legs towards the spine during
upright activities [16]. Additionally, biomechanically, the gluteal muscles, including the
gluteus maximus and medius, play an essential role in stabilizing the trunk and pelvis and
transferring force from the legs to the pelvis during all walking activities, while the gluteus
maximus stabilizes the pelvis, and the gluteus medius and minimus act as key stabilizers
of the pelvis in a single-leg stance position. Therefore, the gluteal muscles play a significant
role in transmitting force from the legs towards the spine during upright activities [17].
Gluteal examinations and interventions are conducted in individuals with low back
pain in clinical practice because the gluteal muscles provide pelvic stability in the coronal
and transverse planes and offer a stable foundation for the lumbar spine [18]. Despite the
close relationship between low back pain and muscles of the spine and hip joints, studies
on concurrent spinal segmental strengthening exercises alongside specific gluteal muscle
strengthening exercises in patients with low back pain are lacking.
The primary outcome measurements of this study are pain, function, and fear avoid-
ance patterns, while the secondary outcome measurement is quality of life. Low back pain
manifests as pain localized below the costal margin and above the gluteal fold, along with
muscle tension or stiffness, and its most significant symptoms are pain and disorder [19].
Low back pain is the most common cause of functional disability, and functional disability
assessment is one of the most important components of medical services [20]. Individuals
with chronic low back pain often exhibit avoidance beliefs towards movement, which
manifest as fear of movement [21]. Negative beliefs about pain lead to negative information
about the illness, causing patients to imagine the worst possible outcomes and creating fear
that leads to avoidance of movement [22]. Additionally, quality of life is a multidimensional
concept used to measure an individual’s health. Over the past few years, there has been
significant interest in investigating the impact of physical and psychological issues on
overall quality of life, as the shift from biomedical issues to biopsychosocial issues has
occurred. Furthermore, the transition to psychosocial issues has been shown to play a
Medicina 2024, 60, 849 3 of 13

crucial role in ensuring positive outcomes from both the clinical and patient perspectives.
Therefore, based on the objectives of this study, the following hypotheses were formulated:

Hypothesis 1. Gluteal muscle strengthening exercise-based core stabilization training (GSE-based

CST) will have differential effects on pain in patients with chronic low back pain.

Hypothesis 2. GSE-based CST will have differential effects on function in patients with chronic
low back pain.

Hypothesis 3. GSE-based CST will have differential effects on fear avoidance patterns in patients
with chronic low back pain.

Hypothesis 4. GSE-based CST will have differential effects on quality of life in patients with
chronic low back pain.

Hypothesis 5. There will be differential effects on pain, function, fear avoidance patterns, and
quality of life between GSE-based CST and the control group.

2. Materials and Methods

2.1. Participants
This study included 34 adult patients with chronic low back pain at the S Hospital,
Seoul, South Korea. Before recruiting the participants for this study, we performed a
power analysis using G*Power version 3.1.9.7 20 (Heinrich-Heine Universität, Düsseldorf,
Germany); an overall effect size index of 0.85 was obtained for all the outcome measures,
with a probability of 0.05, to minimize type II errors (power of 80%). Because the estimated
target sample size was 36, we recruited 40 participants who underwent physical therapy.
Inclusion criteria were individuals aged ≥20 years who experienced daily low back
pain for a minimum of eight weeks, with pain localized just below the iliac crest to the
gluteal fold, and with or without leg pain. This study targeted individuals experiencing
pain or discomfort persisting for ≥12 weeks. Exclusion criteria included individuals with
red-flag conditions, such as cancer, metabolic disorders, rheumatoid arthritis, osteoporosis,
or long-term steroid use; those with acute pain [23]; those with immediate issues due to
nerve compression; those who underwent lumbar surgery; pregnant women [24]; those
with fractures, gastrointestinal or bladder dysfunction, or central nervous system problems;
and individuals with sensory deficits or numbness in the lower extremities [25].
All the participants signed a consent form after the procedure, and the purpose of the
study was explained. This study was approved by the Sahmyook University Institutional
Review Board (approval number: SYU 2022-07-023) and Clinical Research Information
Service (KCT0007883). The participants fully understood the objectives and procedures
used in the study. The study adhered to the ethical principles of the Declaration of Helsinki.

2.2. Experimental Procedure

This study obtained approval for review of medical records confirming clinical charac-
teristics, such as onset date, cause of onset, and medical history before the study. General
characteristics were assessed based on age, height, weight, and body mass index (BMI).
Physical therapists responsible for examination conducted pre-tests one hour before group
allocation. To minimize bias and errors in the experiment, the researchers used the Research
Randomizer program (http://www.randomizer.org/, accessed on 4 September 2022) to
randomly assign the participants to the two groups, thereby minimizing bias and ensuring
a fair experiment. Among the 40 recruited participants, three were excluded because they
did not meet the selection criteria of a numeric pain rating scale (NPRS) score of ≤2, and
three were excluded because they did not meet the age criteria. Consequently, the final
allocation resulted in 17 participants each in the GSE-based CST and control groups based
on the treatment method. The GSE-based CST group underwent gluteal strengthening
 and rating
andensuring andand
ensuring ascale
afair and
(NPRS)
ensuring
fair
ensuring and aensuring
experiment.and
experiment.
and
ensuring
fairascore
fair afair
of
ensuring
Among fair
≤2,
aexperiment.
ensuring
Among
experiment. aexperiment.
aand
thefair
fair
the
experiment.
Among three
40experiment.
recruited
Among
experiment.
40 Among
were
recruited
Among
the theexcluded
40 40
Among the4040recruited
participants,
Amongrecruited
participants,
the
recruited therecruited
because
the three
4040
participants,
three
participants,recruitedparticipants,
they
recruited
were
were did
excluded
participants,
three not
participants,
three
participants,
excluded
were three
meet
were
three were
the
three
excluded
three
were
excluded excluded
wereexcluded
were
excluded excluded
because age
they
because becausecriteria.
did
because
they didthey not because
Consequently,
not meet
they
meet
becausedid didthey
because
the
because
themeet
they
not not did
selection
did the
they
meet
selection
they not
final
thedid
not did meet
criteria
the
meet not the
allocation
meet
of
selection
criteria
notthe
selection meetof aselection
athe
selection
criteria resulted
numeric
the
criteria
numeric
selection criteria
selectionpain
of
ofcriteria in
a
a numeric 17 of
rating
criteria
numeric
paincriteria
ofrating a
a pain numeric
participants
scale
ofof a
pain
scale
numeric (NPRS) pain
numericeach
rating
a numeric
rating (NPRS)
pain scale rating
in
score
pain
scale
pain
score
rating the
(NPRS) scale
GSE-
rating
(NPRS)
rating
scale (NPRS)
scale
score
scale (NPRS)
(NPRS)
score score
(NPRS) score
score score
ofof≤2, based
≤2,and
and three
of CST
of
three
≤2, and and
were
≤2,wereof
ofand
≤2,≤2,
three and
control
excluded
of
three
excluded
of
and
were ≤2,
≤2, three
groups
were
three because
and
andbecausewere
three
were
excluded based
three
excluded excluded
they
were
theyon
were
excluded
because did the
excluded
because
did not
excluded because
treatment
not meet
they
because
they meet
did did
becausethey
because
the method.
the
they
not age
not
age
did
meetdid
they
meet
they not
The
criteria. did
criteria.
not
the did meet
the
meet
age GSE-based
notage
thethe
Consequently,
not meet age
criteria.
Consequently,
meet
criteria. age the
the criteria.
CST age group Consequently,
criteria.
Consequently,
age
criteria.
Consequently, criteria. Consequently,
Consequently,
Consequently,
the finalunderwent
the finaltheallocation
the
allocation the
gluteal
final
final the final
resulted the
allocation
resulted allocation
strengthening
in
final
theallocation
final
allocation final 17
in 17 allocation
resulted
resulted allocation resulted
participants exercises
participants
resulted in 17
resulted
in 17 participants in
resulted
each for17 in
participants
ineach 15
in participants
in the
in 17
17 participants min
17 and
GSE-based
participants
each
theparticipants
each GSE-based
in the CST
ineach the forin
CST
each15the
GSE-based
ineach
eachGSE-based CSTthe in min
andin
and GSE-based
the
GSE-based
CST three
control
the CST
control times
GSE-based
GSE-based
andCST andCST a
controlandand
CST
control control
and control
CSTcontrol
and control
groups
Medicina based
week
2024,
groups based foron
groups
60, 849
groupsonbased the
four groups
treatment
weeks,
based
the treatment
groups based
groups
groups
on on
based while
the on
method.
based
based
on
the treatment the the
treatment
method.
theon on treatment
The
control the
the
treatment
method. GSE-based
treatment
group
method.
The treatment
GSE-based method.
method. The
The GSE-based CST
method.
underwent Thegroup
GSE-based
method.
CST
The group GSE-based
The
CST
The underwent
GSE-based
for
CST
CSTGSE-based
GSE-based 30
underwent
group CST
min
group
CSTunderwent group
gluteal
CST
three
underwent
CST
groupgluteal underwent
group
times
group
underwent aunderwent
gluteal
underwent
gluteal gluteal gluteal
glutealgluteal 4 of 13
week
strengthening
strengthening for four
exercises
strengtheningstrengthening
exercises
strengthening weeks.
for Pre-
strengthening
15 min
exercises
strengthening
for 15 min
strengthening
exercises exercises
and
and
forand
exercises for CST
15 exercises
CST
min for
post-evaluation
exercises
15 min
forandfor 15
15 15and min
for
formin
min
CST 15
CST
15
and
forand
items
three
min
min for
three
CST
15 CSTand
times
15
and
min for
included
min
times
for CST
CST
threea 15
week
three
15amin formin
fora
week
times 15
15 three
NPRS,
for min
times
min
for
three four a
fourtimes
disability
threeweeks,
week
three
times
a week a
times
weeks,
for week
for
atimes index,
a
four
four aweeks,
week for
week
week
for four
weeks,
four for
for weeks,
four weeks,
four weeks,
weeks,
while
whilethe fear avoidance
control
thewhile while
control the while
group
the
group
while
control the
behavior,
underwent
while
control
while
underwent
the control
control
group and
the
group
the group
quality
control
CST
control
CST
group
underwent for
underwent for underwent
of30
group
30
group life
min
underwent
CST underwent
CST
min three
underwent
for for
three
30CSTCST
measurements. times
30
min for
min
times
for CST
CST a30
30
three aweek min
Pre-
for
three
for
week
mintimes3030
forthree
and
timesmin
afour
for
threemin times
post-evaluations
three
weeks.
athree
four
times
week week
weeks.
for aweek
times
atimes week
for
four Pre-
four
Pre- for
afor
week
aweeks.
week four
were
weeks.
four for
for weeks.
fourweeks.
Pre-
four
weeks.
Pre- Pre- Pre-
weeks.
Pre- Pre-
and
andpost-evaluation
conducted
andand
post-evaluation and
anditems
items
post-evaluation post-evaluation
independentlyand
post-evaluationincluded
and post-evaluation
exercises
included and aincluded
items
post-evaluation
post-evaluation
items aNPRS,
at
for items
the
NPRS,
items 15same
included min included
disability
items
aitems
included
NPRS,and
disability included
aexamination
NPRS, CST
included aNPRS,
index,
aindex, NPRS,
disability forfear
aafear
disability 15disability
NPRS,
NPRS, avoidance
locationminindex,
avoidance
disability
index, three
disability
fear index,
disability
to index,behavior,
ensure
fear fear
index,
avoidance
times
behavior,
avoidanceindex,
fear avoidance
consistency,and
fear
aavoidance
week
fear
and behavior,
behavior, for behavior,
avoidance
and four
avoidance and
behavior,
and weeks, and
behavior,
behavior,
and andthe
while
and
quality the
quality ofof therapists
life quality
measurements.
quality
life measurements.
quality of
ofquality of
responsible
quality
life
quality life
Pre-
of lifePre-
life measurements. of
measurements.
control of measurements.
for
and
life
group
life the evaluations
post-evaluations
measurements.
Pre-
underwent
andmeasurements.
measurements. and
post-evaluations
Pre- and Pre- Pre- and
did Pre-
were
post-evaluations
CST
and post-evaluations
not
forand administer
conducted
30
Pre-post-evaluations
post-evaluations were post-evaluations
and conductedmin were
three
post-evaluations
were conducted any werephysical
independently
conducted
times
independently
were conducted conducted
were
a
were week therapy
conducted independently
independently
for
conducted
independently four independently
independentlyand
independentlyweeks. Pre-
and at intervention.
the
and at the same
and and
sameat the at and
examination
andthe
examination
same atand
same
at and
the post-evaluation
the same
location
at the
examination
atlocation
same
examination examination
same
to
theexamination
same ensure
location items
examination
location
to examination
ensureto included
location
consistency,
to
location
ensure ensure
consistency,
location
to to
location a
ensure
and NPRS,
to
the ensure
consistency,
ensureand
consistency, to ensure
the disability
consistency,
therapists consistency,
and
therapists
andconsistency,
consistency, the index,
and
responsible the
therapists
responsible
and
the therapists theandand fear the avoidance
therapists therapists
responsible
the therapists
therapists
responsible responsiblebehavior,
responsible
responsible
responsible and
for the The
evaluations
for
for the evaluations the
for the evaluationsfor
physical
did the
not
evaluations
fordidthenot
for quality
evaluations
therapists
foradminister
the
the did
administer
didevaluations
evaluations ofnot life
did
not administerdid
involved
evaluations any measurements.
not
physical
did
administer
any administer
notphysical
did in notthetherapy
administer
any
not administer
administer
any therapy
physical Pre-
any
intervention
physical and
physical
intervention.
any post-evaluations
had
therapy
intervention.
any physical physical
any physical
therapy therapy
at
therapy
intervention.least
therapy
intervention.
therapy three
intervention. were
intervention. yearsconducted
intervention.
intervention. of independently
The experience
The physical
physical and
Thetherapists
The were
physical
therapists
physicalThe and
Thephysical
involved
The
The at physical
physical
well-versed the
physical
therapists
involved
therapists same
therapists
in
therapistsinthe
inthe
involved examination
potential
therapists
involved
therapists involved
intervention
intervention
involved
in theinissues
the
involvedlocation
involved
in in
had the
that
intervention
had
interventionthe in
at to
may
least
the ensure
intervention
atintervention
in
least
the
had arise
three
had consistency,
intervention
three
at leastwhen
intervention
at had
years
least
years
had three at least
applying
atof had
expe-
three
had
of expe-
least at
years and
at the
three
GSE-
least
years
least
threeof therapists
years
three
of
three
years
expe- expe- ofexpe-
years
years
of responsible
expe-
ofexpe-
of expe-
rience
rienceandbased
and were
rience CST
rience
were and rience
well-versed
andand CST
well-versed
rience
were wereand
rience
and for
rience in the
were
(controland evaluations
potential
well-versed
in
were
well-versed and well-versed
were
potential
were in issues
group).
well-versed well-versed
in The did
potential
well-versed
issues
potential in in
that
that not
potential
same may
may
potential
issues administer
intherapist
issues
in potential
arise
that issues
potential
arise when
that
issues
may when any
may that
issues
issues
that
arise physical
applying
administered may
arisethat
applying
may that
when arise
may
when
may
arise therapy
GSE-based
all when
arise
treatments
applying
GSE-based
arise
when
applying intervention.
applying
when
when
applying GSE-based
GSE-based GSE-based
applying
to GSE-based
applying GSE-based
GSE-based
CST and ensure
CST andCST CST CST
CSTand and
(controlCST
consistency.
(controlCST CST
CST and and
group).
CST CSTand
(control
group).
CST
(controlCST andTheThe
The CST
same
CST physical
(control
group).
(control
group). same group).
(control
therapist
(control The therapists
therapist
group).
The same The
group).
sameadministered
group).
The involved
same
The
therapist
administered
same
therapist therapist
same
The therapist
same in
all the
therapist
administered
administeredall
therapist intervention
administered
treatments
treatments administered
allto had
ensureall
treatments
alladministered
administered to all
treatments ensure at least
treatments
all to
allensure
treatments
to three
treatments
ensure
treatments to years
ensure
to ensure to of experi-
to ensure
ensure
consistency.
consistency. consistency.
consistency. consistency. ence
consistency.
consistency.
consistency. and were well-versed in potential issues that may arise when applying GSE-based
2.3. Training ProgramCST and CST (control group). The same therapist administered all treatments to ensure
2.3.
2.3.Training
Training Program
2.3.In2.3.
Program
this
Training 2.3.
Training
2.3. Training
2.3.
2.3.
Training
study,
Program consistency.
Program
TrainingProgram
Training
Program
GSE-based Program
Program
CST was conducted to improve pain, function, fear
InInavoidance
this
thisstudy,
study,
In this InIn
behavior,
GSE-based
In this
GSE-based
study, this
and
study,
this In study,
CSTquality
InCST
this
this
study,
GSE-based
2.3.
was
wasGSE-based
of
study,
GSE-based
study, life
conducted
GSE-based
Training CST CSTin was
conducted
GSE-based
Programwas CST
patients
GSE-based
CST was
totoconducted
improve
CST
improve
CST
was
conducted conducted
withwaslow
was
pain,
conducted
to to back toimprove
conducted
improve
pain,
conducted
improve improve
pain.
function,
function,
to pain, tofear
pain,
to pain,
improve
avoid- function,
pain,
function,
improve
fear avoid-
pain,
function, fear
pain,
function,
fear fearavoid-
function,
avoid-
function,
avoid-fear avoid-
fearavoid-
fear avoid-
ance behavior,
ance behavior, and
ance
and ance
qualitybehavior,
behavior,ance
quality
ance
ance behavior, of
anceoflife
and inand
behavior,
behavior,
behavior,
and lifeand
quality inof quality
patients
quality and
of
patients
quality
life life
ofof
with
in
andinquality
with life
quality
low in
of
patients
lifelow
patients ofwith
in patients
back
life
life
back in
pain.
with
inlow
patients with
patients
low
pain.
patients
with low
back
backlow with
with
pain. back
low
pain. pain.
lowpain.
back back pain.
back pain.
2.3.1. GSE-Based CST In this study, GSE-based CST was conducted to improve pain, function, fear avoidance
2.3.1. 2.3.1. behavior,
GSE-Based and quality
CST of life in patients with low back pain.
2.3.1.GSE-Based
GSE-Based CST
2.3.1.
Gluteal
2.3.1. 2.3.1. 2.3.1.
GSE-Based
CST 2.3.1.
GSE-Based
muscle
GSE-Based CST GSE-Based
CST
GSE-Based
CST
strengthening CST
CST exercise-based CST involves performing gluteal
strengthening
Gluteal
Gluteal muscle
muscle
GlutealGluteal Gluteal
exercises
strengthening
Gluteal
muscle 2.3.1.
strengthening
Glutealmuscle
and
Gluteal
muscle GSE-Based
muscle strengthening
promoting
exercise-based
muscle
strengthening
muscle
strengthening CST
exercise-based
strengthening spinal
strengthening
CST exercise-based
stability
exercise-based
strengthening
CST
exercise-based involvesCSTin
involves
exercise-based CST patients
exercise-based
exercise-based CSTinvolves
performing
involves
performing
CST
involves involves
with
CST
CST gluteal
performing
gluteal
involves
performing performing
nonspecific
involves
performing performing
gluteal
performing
gluteal gluteal
gluteal gluteal
gluteal
chronic
strengthening
strengthening low strengthening
back
exercises
strengthening
exercises pain.
and
strengthening
strengthening This
strengthening
promoting
exercises
strengthening
and promoting
exercises exercises
approach
and
exercises
and promoting and
aims
exercises
spinal
promoting
exercises
spinal promoting
to
andstrengthen
stability
and
andstrengthening
promoting
spinalpromoting
spinal
stability in
promoting in spinal
the
patientscore
stability
patients
spinal
stability stability
spinal
spinal muscles
with
in
stabilitywith
in patients in
by
stability
patients
stability patients
targeting
nonspecific in
with
innonspecific with
patientsthe
nonspecific
in nonspecific
patients
with patients nonspecific
with nonspecific
withgluteal
with nonspecific nonspecific
Gluteal muscle exercise-based CST involves performing strength-
chronic
chronicgluteal
lowlow muscles.
back
back
chronic pain.
chronic chronic
pain. low
chronic
low The
Thisback
This
back low
chronic
low back
gluteal
chronic
approach
pain.
approach
pain.back
ening low
low
This pain.
aims
back
This
back
aims
pain. This
strengthening
to
pain.
pain.
This
approach
exercises and approach
tostrengthen
approach This
strengthen
This
approach
aims approach
to
promoting aims
exercise-based
approach
aims the
to the
aims
strengthencore
spinal to
core
toaims strengthen
CST
aims
strengthen muscles
muscles
to
strengthen
the
stabilityprogram
tocore
strengthen
in bythe
strengthen
the by
core
the core
presented
targeting the
muscles
targeting
musclescore
patients the muscles
core
the
coreby
the
muscles
by in bytargeting
this
muscles
targeting
muscles
targeting
with by
nonspecific targeting
the by
bythe thelowthe
targeting
targeting
the
chronic the
back
gluteal muscles.
study
gluteal muscles.is The
based
gluteal Thegluteal
gluteal
gluteal
gluteal muscles. on the
muscles.
gluteal muscles.
gluteal
strengthening
gluteal exercises
The The
muscles.
gluteal
strengthening
muscles.
The muscles.
gluteal
pain. gluteal
The
presented strengthening
exercise-based
gluteal
strengtheningin
Theexercise-based
Thestrengthening
This gluteal
approach gluteal strengthening
Table
strengthening CST
1 exercise-based
program
[18,26,27,28].
exercise-based
strengthening
aimsexercise-basedCST
to strengthen programexercise-based
exercise-based
CST
the presented
CST The
exercise-based CST
program
presented
program
core program
in
exercise
CST program
muscles CST
CST
inthis
presented
bythis
presented programpresented
program
program
presented in
in this
targeting this
presentedin
presented thisin this
in this inmuscles.
the gluteal this
studyiswas
study reorganized,
isbased
based
study ononthe
study
is study
is
the
study
based isbased
and
exercises
basedstudybased
on
exercises
study
is
on the
Thetheis on
CST
presented
is
the based
presented
based
on
exercises
gluteal the
the on
exercises
onexercises
program
inthe
the
inTable was
Table
exercises
presented 1presented
exercises
strengthening based
exercises
presented 1[18,27–29]. on
presented
inpresented
presented
in Table Table
[18,27–29]. in 1Table
the
The in 1[18,27–29].
exercises
exercise
[18,27–29].
The in
1in[18,27–29].
exercise-based Table [18,27–29].
Table
1exercise
Table
CST The 11presented
program
The The
[18,27–29]. was
exercise
[18,27–29].
programThe
exercise
program exercise
in
was Table
The
program
The
exercise
program
presented program
1this
exercise
exercise
inprogram
was was was
program
program
studywas wason
was
is based
[27,28].
reorganized,
reorganized, and
andthe
reorganized, reorganized,
reorganized,
the CSTCST
and reorganized,
program
and the
reorganized,
reorganized, program
the
theCST and
and was
CST the
was
the and
and
program
exercises CST
basedthe
program
based
CST the program
onCST
CST
on
program
was
presented the
was
the
program
based
in was
program
exercises
based
exercises
was
onbased
Table based
on
the 1was
was on
presented
the based
presented
based
on
exercises theon
exercises
the
[18,26–28]. onexercises
ininthe
Table
the
exercises
presented
The Table 1 presented
exercises
presented [28,29].
exercises
1in in
[28,29].
presented
exercise presented
Table inTable
presented
Table 1Table
1in[28,29].
program in
was 1[28,29].
[28,29].
in1Table
[28,29].Table 11[28,29].
[28,29].
reorganized, and
the CST program was based on the exercises presented in Table 1 [27,28].
Table Table
Table1.1. 1.Table
Gluteal
Gluteal
Table 1.Table
Gluteal
muscle 1.
muscle
Gluteal
1.muscle
Table
Gluteal 1. Gluteal
strengthening
Table 1.1.
muscle
strengthening
Table
Gluteal
muscle muscle
strengthening
Gluteal strengthening
exercise-based
exercise-based
muscle
strengthening
Gluteal
exercise-based
muscle muscle exercise-based
core
strengthening
core
corestabilization
exercise-based
strengthening
strengthening
strengthening core
stabilization
exercise-based
exercise-based core corestabilization
stabilization
exercise-based
training stabilization
training
(GSE-based
coretraining
stabilization
exercise-based
training
core
stabilization (GSE-based
core
training training
(GSE-based
stabilization
CST). (GSE-based
CST).
training
(GSE-based
stabilization
CST).
training
(GSE-basedtrainingCST). CST). CST).
(GSE-based
(GSE-based
(GSE-based
CST). CST). CST).
Table 1. Gluteal muscle strengthening exercise-based core stabilization training (GSE-based CST).
-- - - exercises:
Gluteal
Gluteal - Gluteal
Gluteal
exercises:-clamshell
--clamshell
Gluteal
exercises:
-clamshell
Gluteal Gluteal
exercises: exercises:
exercise,
Gluteal
exercises: donkey
clamshell
exercise,
Gluteal clamshell
exercise,
donkey
exercises:
clamshell donkey
exercises:
kick
exercise,
exercises:
clamshell
exercise, kick exercise,
kickkick
clamshell
exercise,
donkey
clamshell
exercise,
exercise,
donkey donkey
exercise,
single-leg
exercise,
kick
donkey kick
donkey
bridge
exercise,
exercise,
single-leg
donkey
kick
exercise, exercise,
single-leg
bridge bridge
exercise,
kick
single-leg
kick single-leg
exercise,
exercise,
single-leg exercise,
exercise,
adductor
bridgebridge
exercise, bridge
adductor
single-leg
stretch
exercise,
adductor
single-leg
single-leg exercise,
stretch
bridge
adductor
stretch
bridge
exercise, bridge
exercise,
adductor adductor
exercise,
stretch
exercise,
adductor
stretch stretchstretch
adductor
adductor
stretch stretch
exercise, exercise,
and
exercise, and andand
adductor
exercise,
adductor
exercise, exercise,
adductor
muscles and
muscles
and adductor
muscles
exercise,
exercise, and
adductor adductor
abduction
exercise, abduction
and
muscles
abduction
and
adductor
muscles muscles
+ abduction
+bridge
adductor
abduction
adductor
bridge
muscles abduction
+ exercise
bridge
exercise +exercise
muscles
muscles bridge
+abduction
bridge +exercise
bridge
abduction
abduction
+ bridge
exercise exercise
+bridge
bridgeexercise
+exercise exercise
- Gluteal exercises: clamshell exercise, donkey kick exercise, single-leg bridge exercise, adductor stretch exercise, and adductor
- stabilization
- - muscles
Core
Core - Core
Core
abduction -+
stabilization-- training:
Core
training:
Core
-stabilization
- stabilization training:
Core
bridge stabilization
abdominal
Core
stabilization
abdominal
Core training:
abdominal
stabilization
muscle
training:
stabilization
stabilization
training:
exercise muscle abdominal
muscle
exercises,
training:
abdominal dead
exercises,
training:
abdominal training:
abdominal
muscle dead muscle
exercises, dead
abdominal
muscle bug exercises,
bug
exercise,
muscle
exercises,
abdominal
bug
muscle
exercises, and
dead
exercise,
muscle
exercises,
dead bug bug
and dead
exercise,
dead bug
and
exercises,
crunch
exercise,
exercises,
crunchdead
bug
exercise, and exercise,
crunch
exercise
dead bug
and
exercise
bug and
exercise
(Table
crunch
exercise,
crunch(Table
and crunch
(Table
exercise, and
exercise
exercise,
exerciseand
crunch exercise
crunch (Table (Table
exercise
(Tableexercise
crunch
exercise
(Table (Table (Table
2)2) 2)
2) 2)training:
2) 2)
2) 2)
- Core stabilization abdominal muscle exercises, dead bug exercise, and crunch exercise (Table 2)
- -
Section:
- - Section: 15 -
Section:
times,
- 1515times,
Section: 3-
15 times,
sets
Section:
- 33sets
times,
Section: sets
15 15-
Section:
each3
Section:
times, sets
times,
15 15
each
sets times,
Section:
3 each
-each3 Section:
each 15
sets15
times, 3times,
each sets
3 times,
sets each
33sets
each setseach
each

Clamshell
Clamshellexercise
Clamshell Clamshell
exercise
exercise
Clamshell Clamshell
exercise
Clamshell exercise
Clamshell
exercise exercise
Donkey
Clamshell
Clamshell
Donkey kick
exercise exercise
exercise
Donkey
kick
exercise
Donkey Donkey
Donkey
kick
exercise Donkey
kick
kick
exercise
Donkey
kick kick
Donkey
Donkey
kick
exercise exercise
exercise
exercise kick
Single-leg
kick exercise
Single-leg
exercise bridge
exercise exercise
Single-leg
bridge Single-leg
bridge
Single-leg
exercise
Single-leg bridge bridge
Single-leg
exercise
bridge exercise
Single-leg exercise
bridge
bridge
Single-leg
Single-leg bridge
exercise bridge exercise
exercise
exercise exercise

Adductor
Adductor stretch
Adductor exercise
stretch
Adductor
stretch
Adductor Adductor
exercise exercise
stretch
Adductor
stretch stretch
Adductor
exercise
Adductor
stretch
exercise exercise
stretch
Adductor
stretch exercise
Adductor
exercise exercise muscles
Adductor Adductor
muscles
Adductor Adductor
abduction
muscles muscles
abduction
Adductor
muscles muscles
+ abduction
+bridge
Adductor
abduction exercise
abduction
Adductor
bridge
muscles abduction
muscles
+ exercise
bridge +exercise
musclesbridge
+abduction
bridge +exercise
bridge
abduction
abduction
+ bridge
exercise exercise
+bridge
bridgeexercise
+exercise exercise
Adductor stretch exercise Adductor muscles abduction + bridge exercise
Total
Totalexercise
Total
exercisetime is
exercise
Total
time 30 Total
min,
time is
exercise exercise
with
30 Total
time rest
min,
is time
with
30 is
exercise
periods
rest
min, 30
timemin,
between
is
periods
with restwith
30 setsrest
min,
between
periods periods
lasting
with rest
sets30–40
between between
periods
s.
lasting
sets sets
between
30–40 s.
lasting lasting
30–40setss. 30–40
lasting s.30–40 s.
0,R
2024,
xPEER
FOR
Medicina60,REVIEW
PEER
x FOR
Medicina
2024, REVIEW
PEER
60,
2024,
Total REVIEW
x Total
x exercise
FOR
60,PEER
FOR isis30
30
exercise
REVIEW
time PEER min,
Total
time
REVIEW
min, with
Total
is 30 rest
exercise
with exercise
time
min,
rest periods
with time
is 30
periods between
min,
rest is 30 min,
with
periods
between sets
restwith
lasting
between
sets rest
periods 30–40
periods
between
sets
lasting s. between
lasting
30–40 sets
30–40 s.sets30–40
s. lasting lasting s. 30–405 s.of 13
5 of 135 of 13 5 of 135 of 13

TableTable
2. Core
2.
Table
stabilization
Core2.Table TableTable
stabilization
Core2. Core 2. Core
stabilization
training
training
2. (CST). stabilization
training
(CST).
stabilization
Core (CST).
stabilization
training training
training
(CST). (CST).
(CST).

Abdominal
Abdominal muscle
Abdominal
muscle exercises
Abdominal
muscle
exercises
muscle
exercises
Abdominal exercises
Abdominal Dead bug
muscle exercises
muscle Dead
Dead bug
exercise
bug
Dead
exercises exercise
exercise
bug exercise
Dead bug
Dead
exercise CrunchCrunch
bug exercise exercise
Crunch Crunch
exerciseCrunch
exercise exercise
Crunch
exerciseexercise
Total exercise
Total exercisetime
timeis
Total exercise
Total is 30 min,
exercise
time
30 min,
Total with
isexercise
30
time
with
min,
Total rest
isrest
30
with periods
min,
periods
rest
exercise
time is with
30
time isbetween
periods
between
rest
min, 30periods
between
with sets
min,
restsets lasting
lasting
between
withsets
periods sets30–40
lasting
rest 30–40
periodss.
30–40 s.s.30–40
lasting
between between
sets lastings.30–40
sets lastings.30–40 s.

2.3.2.2.3.2.
CST CST2.3.2. CST
2.3.2. CST
2.3.2. CST
For CST,
For CST,
the For
participant
the
CST,participant
For the
CST,participant
lies
For the on
CST, lies
athetable,
onlies
participanta table,
on
bends
participanta table,
lies bends
the
on a knee
liesbends
the
on aknee
table, andthehip
and
table,
bends knee joints,
hip
bends
the and joints,
knee activates
hip
the and joints,
kneeactivates
hip the
and activates
thejoints,
joints,
hip theactivates
activates the the
abdominal
abdominal
abdominal
muscles,muscles,
andmuscles,
abdominal holds
andmuscles,
abdominal holds
the
andmuscles,
contraction
holds
the
and contraction
the
holds
andcontraction
without
the without
holds changing
without
contraction
the changing
the
contractionchanging
withoutmuscle
thechanging
muscle
without the
lengthmuscle
length
changing formuscle
the 10
length
for 10
the for 10length
muscle
length for 10 for 10
s, lying
s, lying
on the
s, on
lying
table
the
s,on
table
andthe
lyings,activating
and
table
on
lyingactivating
the and
on
tableactivating
the abdominal
and the
table abdominal
the
activating
and abdominal
muscles
themuscles
activating while
themuscles
abdominal while
crossing
abdominal while
crossing
muscles the crossing
opposite
muscles the crossing
while opposite
whilethe
arm opposite
armopposite
crossing
the armopposite
the arm arm
and leg
andandleg
and
moving,
and leg
moving,
and
and lying
moving,
leg
and lying
andon
legthe on
lying
table
moving,
and the ontable
and
moving,
lyingthebending
and
table
on
lying bending
the and
on the
table bending
the knee
the bending
and
table knee
andthehip
and and
kneejoints,
bending
thehip
andjoints,
knee and
hip
the andcontract-
joints,
and
knee hip contract-
and andhipcontract-
joints, joints,
and contract-
and contract-
ing the
ingupper
theingupper
abdominal
theing
upper
abdominal
theing abdominal
muscles
the muscles
upper upper bymuscles
abdominal contracting
by contracting
abdominal by contracting
muscles thebyupper
muscles the upper
body
the
contracting
by upper
body
until
contracting until
body
contraction
the upper the contraction
until
bodycontraction
upper of theof
until
body the of
contraction
until the of the of the
contraction
upperupper
abdominal
upper
abdominalabdominal
muscles
upper muscles
upper is muscles
felt
abdominal is[28,29].
felt
abdominal is
[28,29].
muscles felt
This [28,29].
muscles
is movement
This
felt is movement
This
[28,29]. movement
was
Thisrepeated
felt [28,29]. was repeated
was
movement
This 15repeated
movementtimes
was 15 repeated
times
in
was15three
times
in three
repeated in three
15 times 15 times
in three
in three
sets. The
sets.intensity
The
sets.intensity
Theofintensity
sets.theoftraining
The
sets.the of
training
intensity
The the
was training
set
intensity
of was
the atof
set
70%
wasattraining
training
the of
70%
setwas
the
atofmaximum
70%
the
set atof
was maximum
theatstrength
70%
set maximum
of thestrength
70% of that
maximum
the strength
the
thatpartic-
maximum the
that
strengthpartic-
the partic-
strength
that the
that
partic-
the partic-
Medicina 2024, 60, 849 5 of 13

2.3.2. CST
For CST, the participant lies on a table, bends the knee and hip joints, activates the
abdominal muscles, and holds the contraction without changing the muscle length for 10 s,
lying on the table and activating the abdominal muscles while crossing the opposite arm
and leg and moving, lying on the table and bending the knee and hip joints, and contracting
the upper abdominal muscles by contracting the upper body until contraction of the upper
abdominal muscles is felt [27,28]. This movement was repeated 15 times in three sets. The
intensity of the training was set at 70% of the maximum strength that the participant could
exert in one repetition. Each exercise was performed in three sets, with 15 repetitions for
each set, and was conducted three times a week for four weeks (Table 2).

2.3.3. Outcome Measures

Pain was assessed using the NPRS. The NPRS is used to assess chronic low back
pain. It ranges from 0 cm, representing no pain, to 10 cm, representing severe pain. The
NPRS is a simple and highly reproducible tool for patients to express pain intensity. It
has demonstrated high sensitivity and reliability, with an intraclass correlation coefficient
(ICC) of 0.96 [29]. To evaluate patient status, independent locations were provided in
the same place to ensure that the patients could focus on the evaluation, and pre- and
post-evaluations were conducted.
Functional status was measured using the Roland–Morris disability questionnaire
(RMDQ). The RMDQ is a health status measurement tool used to assess physical disability
in patients with low back pain. It is a questionnaire-based tool suitable for assessing short-
term changes in low back pain. The score is calculated by summing the number of items
checked by the respondents. There are 24 items, and the respondents checked the items
that applied to their condition. The score ranges from 0 (no disability) to 24 (maximum
disability), with a higher score indicating greater disability. It is typically administered to
patients with mild-to-moderate low back pain. The test-retest reliability of the 24 items
indicates an ICC ranging between 0.42–0.91 [30]. This study conducted pre- and post-
evaluations at independent locations in the same area to ensure that patients could focus
on the evaluation.
Fear avoidance behavior was measured using the fear avoidance belief questionnaire
(FABQ). The FABQ was developed to assess fear avoidance behavior in patients with
low back pain. The FABQ is divided into two subscales: fear avoidance beliefs about
physical activity (FABQ-PA) and fear avoidance beliefs about work (FABQ-W). The FABQ-
PA consists of items related to physical activity, numbered from 1 to 5. The FABQ-W
consists of items related to work, numbered from 6 to 16. Each item was scored from 0 to
6 points. Items 2–5 had a maximum score of 24 points each, whereas items 6, 7, 9, 10, 11,
12, and 15 had a maximum score of 42 points each. A higher total score indicates greater
fear avoidance beliefs. The test-retest reliability of the FABQ was high (ICC = 0.9), which
correlated with the RMDQ. The correlation coefficients for the FABQ, FABQ-W subscale,
and FABQ-PA subscale were 0.52, 0.63, and 0.51, respectively [31]. This study conducted
pre- and post-evaluations at independent locations in the same location to ensure that
patients focus on the evaluation.
The short form-36 (SF-36), a general health-related quality of life measurement tool,
was used to assess quality of life. The SF-36 measures general health status, but can also
assess health status in specific disease populations. The SF-36 consists of physical (physical
component summary, PCS) and mental (Mental Component Summary, MCS) components.
The scores of the scales were transformed to obtain values between 0–100, with higher
scores indicating better health status. A combination of physical and mental components is
referred to as overall health (global health, GH). Higher scores indicate a higher quality
of life in the respective domains. The test-retest reliability of the Korean version of the
SF-36 ranges between 0.710–0.895, and the internal consistency, measured by Cronbach’s
alpha, ranges between 0.930–0.938 [32]. This study conducted pre- and post-evaluations at
independent locations in the same area to ensure that patients focus on the evaluation.
Medicina 2024, 60, 849 6 of 13

2.3.4. Data Analysis

All statistical analyses were performed using SPSS ver. 23.00 software (SPSS Inc.,
Chicago, IL, USA). Descriptive statistics for the baseline variables were calculated to
characterize and compare the two study groups. The Shapiro–Wilk test was used to
determine the distribution of the general properties and outcome measures of the subjects,
and means with standard deviations were reported for normally distributed variables. A
paired t-test was used to compare the dependent variables before and after the intervention
within each group (intragroup). Independent t-tests were performed to compare the
differences between groups. Statistical significance was set at a p-value of <0.05. There
was a correlation between the Morris assessment and fear avoidance, thus these two
independent variables are not independent. Therefore, the significance level for RMDQ
and FABQ in this study was set at 0.025 two-tailed.

3. Results
3.1. General Characteristics of Participants
In this study, the participants consisted of 34 patients with chronic low back pain
divided into two groups: the GSE-based CST Group with 17 participants, and the control
group with 17 participants. The homogeneity test results indicated homogeneity between
the groups, as shown in Table 3.

Table 3. General characteristics of participants (N = 34).

Characteristics GSE-Based CST Group (n = 17) Control Group (n = 17) t (p)

Age (years) 44.52 (11.50) a 46.70 (10.99) 0.564 (0.577)
Height (cm) 167.29 (7.53) 165.41 (7.85) −0.713 (0.481)
Weight (kg) 60.82 (10.44) 59.35 (10.01) −0.419 (0.678)
BMI (kg/m2 ) 21.59 (2.16) 21.62 (2.82) 0.037 (0.971)
aM(SD), mean (standard deviation); BMI = body mass index; GSE-based CST = gluteal muscle strengthening
exercise-based core stabilization training; control group = core stabilization training (CST).

3.2. Comparison of NPRS, RMDQ, and FABQ

Before the experiment, there were no significant differences between the two groups
in the pre-test values of the NPRS, RMDQ, and FABQ, confirming homogeneity between
the groups. In the comparison between pre- and post-treatments within each group, the
NPRS significantly decreased from 6.76 to 2.41 cm (p < 0.05) in the GSE-based CST group,
and from 6.00 to 2.94 cm (p < 0.05) in the control group. For RMDQ, there was a significant
reduction from 7.00 to 2.47 points in the GSE-based CST group (p < 0.05), and from 6.88
to 3.41 points in the control group (p < 0.05), indicating a statistically significant decrease
after treatment. For FABQ, there was a significant reduction from 55.11 to 32.47 points in
the GSE-based CST group (p < 0.05), and from 54.41 to 36.29 points in the control group
(p < 0.05), indicating a statistically significant decrease after the treatment.
When examining the difference in NPRS between the groups, the difference in pre-
and post-treatment values were 4.35 and 3.05 cm for the GSE-based CST and control groups,
respectively. This indicates a statistically significant difference between the GSE-based
CST and control groups (p < 0.05). When examining the differences in RMDQ and FABQ
between the groups, the GSE-based CST group showed a greater amount of change than
the control group. However, there was no significant statistical difference between the two
groups (Table 4).

3.3. Comparison of QOL

Before the experiment, there was no significant difference in the pre-test values of the
SF-36 PCS, MCS, and GH subscales between the two groups, indicating that the groups
were homogeneous. In the comparison within each group before and after the experiment,
the PCS scores significantly increased in both the GSE-based CST and control groups.
Medicina 2024, 60, 849 7 of 13

Specifically, in the GSE-based CST group, the PCS score increased from 39.77 to 77.35
(p < 0.05), and in the control group, it increased from 49.81 to 70.66 (p < 0.05).

Table 4. Comparison of NPRS, RMDQ, and FABQ.

GSE-Based CST Control Group

Parameters t (p)
Group (n = 17) (n = 17)
Before 6.76 (1.71) a 6.00 (1.76) −1.280 (0.210)
NPRS After 2.41 (1.12) 2.94 (1.59)
(cm) Before-after 4.35 (1.36) 3.05 (1.47) −2.651 (0.012)
t (p) 13.133 (<0.001) 8.534 (<0.001)
Before 7.00 (3.77) 6.88 (4.04) −0.088 (0.931)
RMDQ After 2.47 (2.00) 3.41 (3.14)
(scores) Before-after 4.52 (2.89) 3.47 (1.94) −1.252 (0.220)
t (p) 6.448 (<0.001) 7.375 (<0.001)
Before 55.11 (19.10) 54.41 (16.55) −0.115 (0.909)
FABQ After 32.47 (16.34) 36.29 (19.68)
(scores) Before-after 22.64 (16.31) 18.11 (11.93) −0.924 (0.362)
t (p) 5.723 (<0.001) 6.261 (<0.001)
a Mean (Standard Deviation); GSE-based CST = gluteal muscle strengthening exercise-based core stabilization
training; control group = core stabilization training (CST); NPRS = numeric pain rating scale; RMDQ = Roland–
Morris disability questionnaire; FABQ = fear avoidance beliefs questionnaire.

In both the GSE-based CST and control groups, the MCS scores significantly increased
after the treatment. Specifically, in the GSE-based CST group, the MCS score increased
from 47.86 to 79.01 (p < 0.05), whereas in the control group, it increased from 54.28 to
70.87 (p < 0.05). In both the GSE-based CST and control groups, the GH scores significantly
increased after the treatment. Specifically, in the GSE-based CST group, the GH score
increased from 43.82 to 78.18 (p < 0.05), and in the control group, it increased from 52.04
to 70.76 (p < 0.05). When comparing the differences in PCS between the two groups, the
pre-post difference values were 37.57 points for the GSE-based CST group and 20.84 points
for the control group. The increase in PCS was statistically significant in the GSE-based
CST group compared with that in the control group (p < 0.05).
The difference in MCS between the pre- and post-measurements was 31.15 points in
the GSE-based CST group and 16.59 points in the control group. There was a significant
statistical difference between the two groups (p < 0.05). Global health showed a difference
of 34.36 points for the GSE-based CST group and 18.72 points for the control group between
the measurements before and after the treatment, with a statistically significant difference
between the two groups (p < 0.05) (Table 5).

Table 5. Comparison of QOL.

GSE-Based CST Control Group

Parameters t (p)
Group (n = 17) (n = 17)
Before 39.77 (21.78) a 49.81 (20.54) 1.382 (0.177)
PCS After 77.35 (12.73) 70.66 (18.90)
(scores) Before-after −37.57 (20.42) −20.84 (13.68) −2.805 (0.009)
t (p) −7.584 (<0.001) −6.283 (<0.001)
Before 47.86 (22.78) 54.28 (17.87) 0.914 (0.367)
MCS After 79.01 (14.18) 70.87 (16.75)
(scores) Before-after −31.15 (23.47) −16.59 (15.23) −2.146 (0.040)
t (p) −5.473 (<0.001) −4.492 (<0.001)
Before 43.82 (20.61) 52.04 (17.85) 1.244 (0.223)
GH After 78.18 (11.64) 70.76 (17.19)
(scores) Before-after −34.36 (20.66) −18.72 (11.56) −2.724 (0.012)
t (p) −6.857 (<0.001) −6.676 (<0.001)
a Mean (Standard Deviation); GSE-based CST = gluteal muscle strengthening exercise-based core stabilization
training; control group = core stabilization training (CST); PCS = physical component summary; MCS = mental
component summary; GH = global health.
Medicina 2024, 60, 849 8 of 13

4. Discussion
4.1. Changes in Pain
Pain is defined as actual or potential tissue damage associated with unpleasant sen-
sations and emotional experiences [2]. Low back pain refers to pain localized below the
lower rib margin and above the gluteal fold, and is often accompanied by muscle tension
or stiffness. The most significant symptoms of non-specific low back pain are pain and
disability [19]. The characteristics of chronic low back pain include pain or discomfort
persisting for 7–12 weeks or longer, with or without symptoms radiating to the legs [13].
Furthermore, regarding the influence of muscles on low back pain, hip muscles play a
crucial role in transmitting forces from the legs to the spine during upright activities,
theoretically affecting the development of low back pain [16].
Within-group differences in this study show that the GSE-based CST group showed
a statically significant decrease in NPRS from pre- to post-treatment, and the control
group also showed a statistically significant decrease in NPRS from pre- to post-treatment.
These findings indicate that Hypothesis 1 was accepted. And regarding between-group
differences, only the GSE-based CST group showed a statistically significant decrease in
NPRS compared to the control group, thus supporting Hypothesis 5.
Fukuda et al. [18] conducted a study on 70 patients with non-specific low back pain,
investigating the effects of exercise therapy, CST, and gluteal muscle strengthening exercises.
According to the study results, there was a significant decrease in visual analogue scale
(VAS) score from 5.5 to 2.3 points in an experimental group (p < 0.05). Bade et al. [27]
conducted a study on 90 patients with non-specific low back pain, implementing back
pain-related training and hip-strengthening exercises to investigate their effects on the
VAS. They observed a decrease in VAS scores from 5.1 to 1.1 in an experimental group and
from 5.4 to 1.9 in a control group, showing a significant difference between the two groups
(p < 0.05). Similar to previous studies, our study confirmed significant differences within
the groups in the evaluation of the NPRS.
Chronic low back pain often manifests as localized pain and a considerable proportion
of widespread pain, which may indicate a worse prognosis. However, exercise therapy
can help reduce pain and improve or maintain function in patients with chronic low back
pain [6]. Furthermore, evidence suggests that exercise modulation training in individuals
with recurrent low back pain reduces pain intensity [33]. In individuals with non-specific
chronic low back pain, core stabilization exercises have been shown to be more effective in
reducing pain and improving functional status compared to traditional exercises [34]. This
study demonstrated that exercise-based CST, which focused on strengthening the muscles
around the spine, improved the tension in the muscle fibers associated with chronic pain.
Additionally, it increased the activity of the surrounding muscles and enhanced the role
of joint mobility, leading to changes in the muscle activity of the buttocks and spine and
reducing excessive tension around the waist and pelvis, thereby improving pain.

4.2. Changes in Function

Back pain is the most common cause of functional disability, and functional disability
assessment is one of the most important components of medical services [20]; patients with
chronic pain recover function, pain decreases, and function improves [35]. In relation to
chronic pain, functional disability has been shown to have a negative impact on patients’
quality of life, encompassing not only physical but also psychological and social aspects [21].
In this study, within-group differences in this study show that the GSE-based CST group
experienced statistically significant increases in RMDQ from pre- to post-treatment, and
the control group also experienced statistically significant increases in RMDQ from pre-
to post-treatment. These findings indicate that Hypothesis 2 was accepted. Regarding
between-group differences, although the GSE-based CST group exhibited more changes
than the control group, no significant differences were observed between the groups, and
thus Hypothesis 5 was rejected.
Medicina 2024, 60, 849 9 of 13

Bade et al. [27] compared the effects of hip exercises in a study involving 30 patients
with non-specific chronic or recurrent low back pain. In the study, experimental groups
1, 2, and 3 underwent hip rotation stretching, multidirectional hip stretching, and hip
strengthening training, respectively. The results showed a significant difference among
the three groups, with experimental group 1 decreasing from 18.2 to 14.8 points, 18.6 to
13.2 points in experimental group 2, and 18.6 to 9.6 points in experimental group 3 (p < 0.05).
Chronic low back pain is a significant health issue, with the most important symptoms
being pain and functional impairment [30]. Patients with disabilities caused by recurrent
back pain may experience limitations in daily activities and inappropriate neuromuscular
adaptations to maintain function [36].
In the treatment of chronic back pain, programs vary widely, but stabilization exercises
are considered most effective, and CST has been shown to reduce pain and improve
functional disability [37]. Core stabilization training based on gluteal muscle-strengthening
exercises is believed to enhance the stability in the spine and pelvis, leading to reduced
back pain and improved function. Although no significant differences were observed
between the groups, this could be attributed to the influence of the intervention duration,
as suggested by previous studies. Therefore, differences between the groups may emerge
in functional aspects if the experiment was evaluated and conducted over a longer period.
Furthermore, in this study, the gluteal muscle strengthening exercise-based CST showed an
overall improvement in lumbar function, which was considered to be effectively enhanced.

4.3. Changes in Fear Avoidance Behavior

Individuals with chronic low back pain often exhibit fear avoidance beliefs regarding
movement, which manifests as kinesiophobia [21]. Negative beliefs about pain can lead to
physical, psychological, and quality of life problems. These negative beliefs can instill fear
in patients, leading them to imagine the worst possible outcomes related to their condition
and avoid movement. Such outcomes can have negative repercussions, leading to actual
or anticipated painful experiences and exacerbating the detrimental effects. Within the
initial six months, patients experiencing fear of movement often reported more pain and
disability. This study used the FABQ. Within-group differences in this study show that the
GSE-based CST group experienced statistically significant increases in FABQ from pre- to
post-treatment, and the control group also experienced statistically significant increases in
FABQ from pre- to post-treatment. These findings indicate that Hypothesis 3 was accepted.
Regarding between-group differences, although the GSE-based CST group exhibited more
changes than the control group, no significant differences were observed between the
groups, and thus Hypothesis 5 was rejected.
Kim et al. [38] performed simulated horseback riding exercises in 48 patients with
chronic low back pain. The FABQ scores for the physical component decreased from 15.35
to 8.80 in an experimental group, while in a control group, they decreased from 11.93 to
11.10. There was a significant within-group difference in the experimental group (p < 0.05)
but not in the control group. Back pain is very common; however, when back pain disorders
persist beyond the normal healing time and progress to chronicity, a specific underlying
mechanism cannot be assumed.
Chronic back pain is generally accepted to be multifactorial in nature, with psychologi-
cal and social factors as characteristic elements that can influence pain-avoidance behaviors
that may impact disability, which varies individually [39]. Psychological factors influence
the onset of chronic back pain and can contribute to fear avoidance patterns. These patterns
have been identified as important psychosocial variables related to back pain in patients
with chronic disabilities [40], and reductions in fear avoidance patterns have been shown to
correlate with decreases in pain and disability in chronic back pain [41]. Pain and functional
disability are influenced not only by pathological issues but also by psychosocial factors. In
this study, pain reduction and functional improvement were observed in the GSE-based
CST group. According to these results, significant differences were also observed in fear
Medicina 2024, 60, 849 10 of 13

avoidance patterns in the GSE-based CST group due to pain reduction and functional
improvement.

4.4. Change in Quality of Life

The concept of determinants of health-related quality of life has evolved since the
1980s to encompass broader aspects of quality of life that can clearly impact physical or
mental health [42]. The SF-36 is a highly popular tool for evaluating health-related quality
of life, and it broadly consists of physical and mental components that can be summarized
into two factors [43,44]. This study used the SF-36. Within-group differences indicate that
both the GSE-based CST group and the control group experienced statistically significant
increases in PCS, MCS, and GH from pre- to post-treatment. This suggests that Hypothesis
Fourth was accepted. Regarding between-group differences, the GSE-based CST group
showed statistically significant increases in PCS, MCS, and GH compared to the control
group, supporting Hypothesis Fifth for PCS, MCS, and GH.
In a previous study [45], two experimental groups of 66 patients with non-specific low
back pain (experimental group 1, which performed hip stretching exercises alongside core
stabilization exercises, and experimental group 2, which performed gluteal strengthening
exercises alongside core stabilization exercises)conducted a comparative study in a control
group performing core stabilization exercises with concurrent skin contact and those per-
forming stabilization exercises alongside manual therapy or solely performing stabilization
exercises. According to SF-36 scores for the PCS, the experimental group 1 increased from
29.69 to 47.51 points, experimental group 2 increased from 30.42 to 47.34 points, and the
control group increased from 30.44 to 38.99 points, showing significant differences among
the three groups (p < 0.05). According to results from MCS, experimental group 1 increased
from 46.46 to 60.91 points, experimental group 2 increased from 46.69 to 59.56 points, and
the control group increased from 46.26 to 54.29 points, indicating significant differences
among the three groups (p < 0.05).
Quality of life is significantly correlated with pain acceptance and participation in
pain-related activities. Lower levels of pain are associated with better quality of life, and
pain plays a crucial role in explaining aspects of quality of life in physical and social
domains [46]. Patients who experience pain often have a significantly lower quality of
life compared to those who do not experience pain. Patients with back pain or multiple
pain sites tend to experience pain and disorder, which negatively impacts their overall
health and consequently lowers their quality of life. Changes in pain show the strongest
correlation with quality of life [47]. Health-related quality of life is influenced by chronic
pain in various domains, such as physical and mental health, social relationships, and
functional abilities [48].
Quality of life is associated with pain and functioning. As pain decreases and function
improves, individuals experience higher levels of achievement and satisfaction with their
daily activities. GSE-based CST resulted in decreased back pain, improved lumbar function,
and reduced fear of pain. Improved factors are believed to increase the overall satisfaction
with life for patients with back pain, affecting both physical and mental aspects, resulting in
overall improvement. The GSE-based CST group showed significant differences compared
to the control group. Considering these results, it seems that supplementing CST with
gluteal strengthening exercises, as seen in the GSE-based CST, is more effective than solely
performing the traditional CST (control group) and could be an effective intervention for
enhancing the quality of life in patients with chronic back pain.
Our study has limitations. First, the selection of participants was limited to patients
receiving treatment at the current hospital, which may restrict the generalizability of the
findings to a broader population. Second, the small sample size of 34 participants is small.
This may have limited the statistical power and generalizability of the study findings.
As a result, it may be difficult to generalize the findings of the study to all patients with
back pain, given the limited sample size and restriction to patients receiving treatment
at a specific hospital. Furthermore, although short-term effects could be observed after
Medicina 2024, 60, 849 11 of 13

12 sessions of treatment administered three times a week for four weeks, it was challenging
to demonstrate long-term effects of applying exercise interventions for more than four
weeks.
Moreover, SES-based CST should be applied to a larger number of patients and
implemented in long-term treatment plans to achieve intervention efficacy. Future studies
should quantify and refine gluteal strengthening exercise-based CST for application in
clinical settings, and follow-up studies should be conducted to evaluate the effects of
interventions based on gluteal muscle strengthening exercises on functional and fear
avoidance pattern assessments.

5. Conclusions
This study aimed to investigate the effects of GSE-based CST on pain, function, fear
avoidance patterns, and quality of life in patients with non-specific low back pain. In this
small randomized clinical trial of patients with chronic low back pain, a 4-week exercise
intervention program of gluteal strengthening and core stabilization and a 4-week core
stabilization program were both associated with significantly reduced pain, disability, fear
avoidance, and improved quality of life. However, the combined gluteal strengthening and
core stabilization group made significantly greater gains than the core stabilization group.
Based on this study, it can be proposed that gluteal muscle strengthening exercise-based
core stabilization training is an effective intervention method for future clinical practice.

Author Contributions: Conceptualization, S.-E.A. and B.-H.L.; Data curation, S.-E.A.; Methodology,
S.-E.A. and M.-Y.L.; Project administration, B.-H.L.; Supervision, M.-Y.L. and B.-H.L.; Writing—
original draft, S.-E.A.; Writing—review and editing, M.-Y.L. and B.-H.L. All authors have read and
agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki and approved by the Institutional Review Board of Sahmyook University
(protocol code: SYU 2022-07-023, approval date: 7 September 2022) in Republic of Korea. The protocol
of this trial was retrospectively registered in the Clinical Research Information Service of the Republic
of Korea (KCT0007883).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data are contained within the article.
Conflicts of Interest: The authors declare no conflicts of interest.

References
1. Hoy, D.; Bain, C.; Williams, G.; March, L.; Brooks, P.; Blyth, F.; Woolf, A.; Vos, T.; Buchbinder, R. A systematic review of the global
prevalence of low back pain. Arthritis Rheum. 2012, 64, 2028–2037. [CrossRef] [PubMed]
2. Treede, R.-D. The International Association for the Study of Pain definition of pain: As valid in 2018 as in 1979, but in need of
regularly updated footnotes. Pain Rep. 2018, 3, e643. [CrossRef] [PubMed]
3. Deyo, R.A.; Rainville, J.; Kent, D.L. What can the history and physical examination tell us about low back pain? JAMA 1992, 268,
760–765. [CrossRef] [PubMed]
4. Gb, A. Epidemiological features of chronic low-back pain. Lancet 1999, 354, 581–585.
5. Ehrlich, G.E. Back pain. J. Rheumatol. Suppl. 2003, 67, 26–31.
6. Krismer, M.; van Tulder, M. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-
specific). Best Pract. Res. Clin. Rheumatol. 2007, 21, 77–91. [CrossRef]
7. Frizziero, A.; Pellizzon, G.; Vittadini, F.; Bigliardi, D.; Costantino, C. Efficacy of core stability in non-specific chronic low back
pain. J. Funct. Morphol. Kinesiol. 2021, 6, 37. [CrossRef]
8. Wong, W.S.; Fielding, R. Prevalence and characteristics of chronic pain in the general population of Hong Kong. J. Pain 2011, 12,
236–245. [CrossRef]
9. Serranheira, F.; Cotrim, T.; Rodrigues, V.; Nunes, C.; Sousa-Uva, A. Nurses’ working tasks and MSDs back symptoms: Results
from a national survey. Work 2012, 41 (Suppl. 1), 2449–2451. [CrossRef]
10. Ovayolu, O.; Ovayolu, N.; Genc, M.; Col-Araz, N. Frequency and severity of low back pain in nurses working in intensive care
units and influential factors. Pak. J. Med. Sci. 2014, 30, 70. [CrossRef]
Medicina 2024, 60, 849 12 of 13

11. Delitto, A.; George, S.Z.; Van Dillen, L.; Whitman, J.M.; Sowa, G.; Shekelle, P.; Denninger, T.R.; Godges, J.J.; Beneciuk, J.M.; Bishop,
M.D. Low back pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health
from the Orthopedic Section of the American Physical Therapy Association. J. Orthop. Sports Phys. Ther. 2012, 42, A1–A57.
[CrossRef]
12. Kendall, K.D.; Emery, C.A.; Wiley, P.; Ferber, R. The effect of the addition of hip strengthening exercises to a lumbopelvic exercise
program for the treatment of non-specific low back pain: A randomized controlled trial. J. Sci. Med. Sport 2015, 18, 626–631.
[CrossRef]
13. Kibler, W.B.; Press, J.; Sciascia, A. The role of core stability in athletic function. Sports Med. 2006, 36, 189–198. [CrossRef]
14. Huxel Bliven, K.C.; Anderson, B.E. Core stability training for injury prevention. Sports Health 2013, 5, 514–522. [CrossRef]
[PubMed]
15. Chen, S.; Chang, W.-D.; Wu, J.-Y.; Fong, Y.-C. Electromyographic analysis of hip and knee muscles during specific exercise
movements in females with patellofemoral pain syndrome: An observational study. Obs. Study Med. 2018, 97, e11424. [CrossRef]
[PubMed]
16. Nadler, S.F.; Malanga, G.A.; Bartoli, L.A.; Feinberg, J.H.; Prybicien, M.; DePrince, M. Hip muscle imbalance and low back pain in
athletes: Influence of core strengthening. Med. Sci. Sports Exerc. 2002, 34, 9–16. [CrossRef] [PubMed]
17. Nadler, S.F.; Malanga, G.A.; DePrince, M.; Stitik, T.P.; Feinberg, J.H. The relationship between lower extremity injury, low back
pain, and hip muscle strength in male and female collegiate athletes. Clin. J. Sport Med. 2000, 10, 89–97. [CrossRef]
18. Fukuda, T.Y.; Aquino, L.M.; Pereira, P.; Ayres, I.; Feio, A.F.; de Jesus, F.L.A.; Neto, M.G. Does adding hip strengthening exercises
to manual therapy and segmental stabilization improve outcomes in patients with nonspecific low back pain? A randomized
controlled trial. Braz. J. Phys. Ther. 2021, 25, 900–907. [CrossRef]
19. Koes, B.W.; van Tulder, M.W.; Thomas, S. Diagnosis and treatment of low back pain. BMJ 2006, 332, 1430–1434. [CrossRef]
20. Zamani, E.; Kordi, R.; Nourian, R.; Noorian, N.; Memari, A.H.; Shariati, M. Low back pain functional disability in athletes;
conceptualization and initial development of a questionnaire. Asian J. Sports Med. 2014, 5, e24281. [CrossRef]
21. Cruz-Díaz, D.; Bergamin, M.; Gobbo, S.; Martínez-Amat, A.; Hita-Contreras, F. Comparative effects of 12 weeks of equipment
based and mat Pilates in patients with Chronic Low Back Pain on pain, function and transversus abdominis activation. A
randomized controlled trial. Complement. Ther. Med. 2017, 33, 72–77. [CrossRef] [PubMed]
22. Yilmaz Yelvar, G.D.; Çırak, Y.; Dalkılınç, M.; Parlak Demir, Y.; Guner, Z.; Boydak, A. Is physiotherapy integrated virtual walking
effective on pain, function, and kinesiophobia in patients with non-specific low-back pain? Randomised controlled trial. Eur.
Spine J. 2017, 26, 538–545. [CrossRef] [PubMed]
23. Patrick, N.; Emanski, E.; Knaub, M.A. Acute and chronic low back pain. Med. Clin. N. Am. 2014, 98, 777–789. [CrossRef] [PubMed]
24. Cook, C.; Learman, K.; Showalter, C.; Kabbaz, V.; O’Halloran, B. Early use of thrust manipulation versus non-thrust manipulation:
A randomized clinical trial. Man. Ther. 2013, 18, 191–198. [CrossRef]
25. Burns, S.A.; Cleland, J.A.; Rivett, D.A.; Snodgrass, S.J. Effectiveness of physical therapy interventions for low back pain targeting
the low back only or low back plus hips: A randomized controlled trial protocol. Braz. J. Phys. Ther. 2018, 22, 424–430. [CrossRef]
26. Ikele, C.N.; Ikele, I.T.; Ojukwu, C.P.; Ngwoke, E.O.; Katchy, U.A.; Okemuo, A.J.; Mgbeojedo, U.G.; Kalu, M.E. Comparative
analysis of the effects of abdominal crunch exercise and dead bug exercise on core stability of young adults. Niger. J. Med. 2020,
29, 676–679.
27. Bade, M.; Cobo-Estevez, M.; Neeley, D.; Pandya, J.; Gunderson, T.; Cook, C. Effects of manual therapy and exercise targeting the
hips in patients with low-back pain—A randomized controlled trial. J. Eval. Clin. Pract. 2017, 23, 734–740. [CrossRef]
28. Mostagi, F.Q.R.C.; Dias, J.M.; Pereira, L.M.; Obara, K.; Mazuquin, B.F.; Silva, M.F.; Silva, M.A.C.; de Campos, R.R.; Barreto, M.S.T.;
Nogueira, J.F. Pilates versus general exercise effectiveness on pain and functionality in non-specific chronic low back pain subjects.
J. Bodyw. Mov. Ther. 2015, 19, 636–645. [CrossRef]
29. Ferraz, M.B.; Quaresma, M.R.; Aquino, L.R.; Atra, E.; Tugwell, P.; Goldsmith, C. Reliability of pain scales in the assessment of
literate and illiterate patients with rheumatoid arthritis. J. Rheumatol. 1990, 17, 1022–1024.
30. Macedo, L.G.; Maher, C.G.; Latimer, J.; Hancock, M.J.; Machado, L.A.; McAuley, J.H. Responsiveness of the 24-, 18-and 11-item
versions of the Roland Morris Disability Questionnaire. Eur. Spine J. 2011, 20, 458–463. [CrossRef] [PubMed]
31. Williamson, E. Fear avoidance beliefs questionnaire (FABQ). Aust. J. Physiother. 2006, 52, 149. [CrossRef] [PubMed]
32. Han, C.-W.; Lee, E.-J.; Iwaya, T.; Kataoka, H.; Kohzuki, M. Development of the Korean version of Short-Form 36-Item Health
Survey: Health related QOL of healthy elderly people and elderly patients in Korea. Tohoku J. Exp. Med. 2004, 203, 189–194.
[CrossRef] [PubMed]
33. Aasa, B.; Berglund, L.; Michaelson, P.; Aasa, U. Individualized low-load motor control exercises and education versus a high-load
lifting exercise and education to improve activity, pain intensity, and physical performance in patients with low back pain: A
randomized controlled trial. J. Orthop. Sports Phys. Ther. 2015, 45, 77–85. [CrossRef] [PubMed]
34. Inani, S.B.; Selkar, S.P. Effect of core stabilization exercises versus conventional exercises on pain and functional status in patients
with non-specific low back pain: A randomized clinical trial. J. Back Musculoskelet. Rehabil. 2013, 26, 37–43. [CrossRef] [PubMed]
35. Guzmán, J.; Esmail, R.; Karjalainen, K.; Malmivaara, A.; Irvin, E.; Bombardier, C. Multidisciplinary rehabilitation for chronic low
back pain: Systematic review. BMJ 2001, 322, 1511–1516. [CrossRef] [PubMed]
36. Hammill, R.R.; Beazell, J.R.; Hart, J.M. Neuromuscular consequences of low back pain and core dysfunction. Clin. Sports Med.
2008, 27, 449–462. [CrossRef] [PubMed]
Medicina 2024, 60, 849 13 of 13

37. Kostadinović, S.; Milovanović, N.; Jovanović, J.; Tomašević-Todorović, S. Efficacy of the lumbar stabilization and thoracic
mobilization exercise program on pain intensity and functional disability reduction in chronic low back pain patients with lumbar
radiculopathy: A randomized controlled trial. J. Back Musculoskelet. Rehabil. 2020, 33, 897–907. [CrossRef] [PubMed]
38. Kim, T.; Lee, J.; Oh, S.; Kim, S.; Yoon, B. Effectiveness of simulated horseback riding for patients with chronic low back pain: A
randomized controlled trial. J. Sport Rehabil. 2020, 29, 179–185. [CrossRef]
39. O’Sullivan, P. Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control
impairments as underlying mechanism. Man. Ther. 2005, 10, 242–255. [CrossRef]
40. Fritz, J.M.; George, S.Z.; Delitto, A. The role of fear-avoidance beliefs in acute low back pain: Relationships with current and
future disability and work status. Pain 2001, 94, 7–15. [CrossRef]
41. Wertli, M.M.; Rasmussen-Barr, E.; Held, U.; Weiser, S.; Bachmann, L.M.; Brunner, F. Fear-avoidance beliefs—A moderator of
treatment efficacy in patients with low back pain: A systematic review. Spine J. 2014, 14, 2658–2678. [CrossRef]
42. McHorney, C.A. Health Status Assessment Methods for Adults: Past Accomplishments and Future Challenges. Annu. Rev. Public
Health 1999, 20, 309–335. [PubMed]
43. Farivar, S.S.; Cunningham, W.E.; Hays, R.D. Correlated physical and mental health summary scores for the SF-36 and SF-12
Health Survey, V.1. Health Qual. Life Outcomes 2007, 5, 54. [CrossRef] [PubMed]
44. Lins, L.; Carvalho, F.M. SF-36 total score as a single measure of health-related quality of life: Scoping review. SAGE Open Med.
2016, 4, 2050312116671725. [CrossRef]
45. Kim, B.; Yim, J. Core stability and hip exercises improve physical function and activity in patients with non-specific low back
pain: A randomized controlled trial. Tohoku J. Exp. Med. 2020, 251, 193–206. [CrossRef] [PubMed]
46. Mason, V.L.; Mathias, B.; Skevington, S.M. Accepting Low Back Pain: Is It Related to a Good Quality of Life? Clin. J. Pain 2008, 24,
22–29. [CrossRef]
47. Lamé, I.E.; Peters, M.L.; Vlaeyen, J.W.S.; Kleef, M.V.; Patijn, J. Quality of life in chronic pain is more associated with beliefs about
pain, than with pain intensity. Eur. J. Pain 2005, 9, 15–24. [CrossRef]
48. Husky, M.M.; FerdousFarin, F.; Compagnone, P.; Fermanian, C.; Kovess-Masfety, V. Chronic back pain and its association with
quality of life in a large French population survey. Health Qual. Life Outcomes 2018, 16, 195. [CrossRef]

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.