Journal of Physiotherapy 69 (2023) 93–99

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s

Research

Self-administered stretching exercises are as effective as motor control exercises

for people with chronic non-specific low back pain: a randomised trial
Aline Mendonça Turci a, Camila Gorla Nogueira a, Helen Cristina Nogueira Carrer b,
Thais Cristina Chaves b
a
Health Sciences Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; b Department of Physical Therapy, Federal University of São Carlos,
São Carlos, Brazil

K E Y W O R D S A B S T R A C T

Randomised clinical trial Question: In people with chronic non-specific low back pain, what is the effect of self-administered
Non-specific chronic low back pain stretching exercises relative to motor control exercises on pain intensity, disability, fear avoidance, global
Self-stretching exercises
perceived effect and flexibility? Design: Randomised trial with concealed allocation, intention-to-treat
Motor control exercises
analysis and blinding of assessors. Participants: One hundred people with chronic non-specific low back
Physical therapy
pain. Interventions: The self-stretching exercise group performed 6 stretches in 40-minute sessions. The
motor control exercise group performed trunk stabilising exercises in 40-minute sessions. Both groups
performed weekly supervised sessions for 8 weeks with one or more home sessions/week. Outcome
measures: The primary outcomes were pain intensity (0 to 10 scale) and disability (Oswestry Disability
Index). The secondary outcomes were the Fear Avoidance Beliefs Questionnaire, global perceived effect, and
the fingertip-to-floor test. Measures were taken at baseline and at 8, 13 and 26 weeks. Results: On the 0 to 10
scale, the between-group difference in pain intensity was negligible, with a mean difference of roughly
0 (95% CI 21 to 1) at each time point. Similarly, the between-group difference on the 100-point disability
scale was negligible: MD –1 (95% CI –3 to 1) at week 8, MD 1 (95% CI –1 to 3) at week 13 and MD 0 (95%
CI –1 to 2) at week 26. The two interventions also had similar effects on the secondary outcomes.
Conclusion: In people with chronic non-specific low back pain, self-stretching exercises had very similar
effects to motor control exercises on pain intensity, disability, fear avoidance, global perceived effect and
flexibility up to 18 weeks beyond the end of an 8-week program. Given the established effectiveness of
motor control exercises, either intervention could be recommended to people with chronic low back pain.
The choice of intervention might be directed by patient preference. Registration: NCT03128801.
[Turci AM, Nogueira CG, Nogueira Carrer HC, Chaves TC (2023) Self-administered stretching exercises are
as effective as motor control exercises for people with chronic non-specific low back pain: a randomised
trial. Journal of Physiotherapy 69:93–99]
© 2023 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction to continue with everyday activities. In addition, exercises are

another non-invasive treatment recommended by the NICE guide-
Low back pain is common in all age groups, and it is frequently line7 and were also recommended in a summary of 11 standard/
observed in high, middle and low-income countries.1 It is the leading consistent recommendations obtained across high-quality clinical
cause of disability and lost productivity, with a prevalence over a practice guidelines for musculoskeletal pain conditions.8 In an over-
lifetime of up to 84% for adults.2 Low back pain can be defined as pain view of Cochrane reviews about physical activity and exercise for
or discomfort located between the costal margin and the gluteal chronic pain, the results were inconsistent for pain intensity across
folds, with or without referred pain in the legs, and it is the most studies. However, the review reported small-to-moderate effect sizes
common type of chronic pain.3,4 It is estimated that 85% of low back for physical function.9
pain does not present an identifiable pathoanatomical cause, and no Motor control exercises (MCE) are very commonly used to treat
reliable evidence of a cause can be observed through the available CNSLBP. They are focused on activating the deep trunk muscles and
imaging tests.5,6 When such low back pain lasts for . 3 months, it is targeting the restoration of control and coordination during exercises,
described as chronic non-specific low back pain (CNSLBP). progressing to more complex and functional tasks integrating the
The National Institute for Health and Care Excellence (NICE)7 activation of deep and global trunk muscles.10 Previous systematic
guideline recommends that self-management strategies should be reviews with meta-analysis have demonstrated that MCE is more
provided for patients with CNSLBP. Such strategies include informa- effective than a minimal intervention to reduce pain intensity and
tion on the nature of low back pain and sciatica and encouragement disability.10,11 Previous systematic reviews with meta-analysis have

https://doi.org/10.1016/j.jphys.2023.02.016
1836-9553/© 2023 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
94 Turci et al: Self-stretching and motor control exercises for back pain

found no clinically important difference between MCE and other generated the allocation sequence and assigned participants to the
types of exercise.10,12 Conversely, a network meta-analysis11 showed intervention groups was not involved in their recruitment, assess-
that core strengthening exercises (ie, MCE) showed better effects for ment, intervention or any other task of the study. After the group
pain intensity and disability when compared with other exercise assignment, a second blinded researcher administered baseline
types, but these effects did not meet the minimum clinically impor- questionnaires (ie, appropriately validated questionnaires in Brazilian
tant difference.13 Portuguese) and the fingertip-to-floor test. Afterwards, the partici-
Exercises involving therapeutic whole-body stretching, also called pants received the SSE or MCE interventions as one-to-one sessions
global postural re-education, can treat painful musculoskeletal con- with the same physiotherapist, who was not involved in any other
ditions such as chronic back pain. These exercises aim to promote the task in the study. The treatment period took place over 8 weeks, with
stretching of muscle chains and improve the contraction of the a weekly session23 of 40 minutes. In the first session, participants
antagonist muscles,14–16 that is, the isometric contraction of antago- from each group took home handouts with clear written instructions
nist muscles in association with the active stretching of the target and illustrations on how to perform the exercises. Participants were
muscles (agonists).17,18 invited to perform at least one home session per week. Immediately
In a systematic review,19 global postural re-education had similar after the last intervention, the participants were reassessed for the
effects on pain intensity and disability as other treatments for pa- primary and secondary outcomes. Finally, the participants returned 4
tients with a range of musculoskeletal conditions. A meta-analysis20 and 12 weeks after the end of the treatment for follow-up assess-
on the effectiveness of global postural re-education for treating spi- ment. Those who were unable to return face-to-face were contacted
nal disorders concluded that this might be an effective method for by telephone for the reassessments. This study is reported according
treating spinal disorders, decreasing pain and improving function. to the recommendations of the CONSORT Statement.24
Previous studies have shown that self-stretching exercises for
CNSLBP showed better effects on pain intensity,16,21 function and
Participants, therapists and centres
quality of life16 compared with a conventional physiotherapy pro-
gram of exercises or a waiting list group. In one previous study,22
The inclusion criteria were: age 18 to 60 years; diagnosis of
which was not randomised, global stretching exercises were
CNSLBP in the last 3 months and/or pain located between T12 and
compared with MCE in CNSLBP and better effects were found from
gluteal folds on at least half of the days in the last 6 months;25 pain
stretching exercises on pain intensity, function and global mobility.
intensity  3 on a 0 to 10 numerical pain rating scale; mechanical
Additionally, a previous network meta-analysis11 reported that
pain behaviour caused by postures, activities and movements such as
stretching showed greater effects for pain intensity and disability
flexion and functional movement tasks; and scores . 14% on the
than minimal intervention in chronic low back pain.
Oswestry Disability Index.26 The exclusion criteria were: red flags
Global stretching exercises is a therapist-dependent approach,
(neoplastic diseases or spinal tumours, inflammatory diseases, in-
which is a disadvantage of the method. On the other hand, self-
fections and fractures); presenting severe neurological (central or
stretching exercises (SSE), also called Global Active Stretching®, is
peripheral) symptoms; psychiatric, rheumatological and/or cardiac
an alternative that minimises dependence on the therapist, as the
diseases; signs of radiculopathy, lumbar stenosis or spondylolisthesis;
patients are invited to adopt self-stretching postures, with a contin-
history of spinal surgery; pregnancy; and receipt of physiotherapy
uous increase in autonomy throughout the treatment. Patients sus-
treatment in the 6 months before the evaluation period.
tain the stretching postures through low-level sustained contraction
One physiotherapist who was not involved in the assessments
of the antagonist muscles to those being stretched.
treated the participants. Due to the nature of the interventions, the
However, no previous study has investigated the effect of SSE
therapist could not be blinded. The physiotherapist who delivered the
when compared with MCE for patients with CNSLBP. Therefore, the
interventions was an experienced clinician who was certified in the
primary aim of this study was to compare the effect of SSE with the
SSE approach with 10 years of clinical experience using the SSE
effect of MCE on pain intensity and low back pain-related disability in
approach regularly. The study was conducted in a primary care
patients with CNSLBP immediately and 8 weeks after the treatment
setting from the Centro Saúde Escola Cuiabá - Ribeirão Preto Medical
programs. Considering that self-stretching posture exercises combine
School, University of São Paulo, Brazil.
stretching and contraction in the same approach, we hypothesised
greater benefits from an SSE program on pain intensity and disability
compared with an MCE program. Interventions
Therefore, the research question for this randomised trial was:
Self-stretching exercise
In people with chronic non-specific low back pain, what is the The SSE protocol was based on the study by Lawand et al,16 who
effect of self-administered stretching exercises relative to motor used a series of stretching postures from the Global Active Stretch-
control exercises on pain intensity, disability, fear avoidance, ing® program described by Souchard27 (Appendix 1 on the eAd-
global perceived effect and flexibility? denda). A certified therapist with experience in the Global Active
Stretching® approach administered the sessions in a standardised
way (Appendix 1), and each exercise posture was sustained for 10 to
20 minutes. The therapist verbally led and guided the treatment
Method postures. Furthermore, because it was an active technique, the par-
ticipants were advised to progress each posture as they felt able
Design during the sustained stretching period. The aim was to achieve
maximal leg extension and maximal ankle dorsiflexion for each
This study was a prospectively registered, two-arm, randomised posture. Maximal shoulder abduction was the target for some pos-
trial with concealed allocation, blinded assessment of some outcomes tures (Appendix 1, picture B weeks 3 and 4) and maximal shoulder
and intention-to-treat analysis. Participants were recruited from adduction for others (Appendix 1, picture B weeks 1 and 2). In
among people with CNSLBP who had been referred to a physio- addition, the participants were advised to decrease low back lordosis
therapy clinic. An initial evaluation was conducted for eligibility (trying to keep their lower back in contact with the surface). Use of a
assessment, in which participants answered questions about de- specific breathing pattern is a fundamental part of the approach and
mographic characteristics, clinical status (including medication use), was instituted during all the postures. During inspiration, the par-
and red flags. A research assistant then conducted the group alloca- ticipants were encouraged to inhale air through the nose, expanding
tion procedure. Participants were randomly assigned to two treat- the region of the lower ribs. During expiration, the top of the chest
ment groups following simple computerised randomisation was lowered and the abdomen was allowed to protrude, as shown in
procedures using opaque sealed envelopes. The researcher who Appendix 1.27
 Research 95

Motor control exercise Data analysis

The MCE protocol that was used was described by Hicks et al,28 as
shown in Appendix 2 on the eAddenda. It was directed by a single The two primary outcome variables (pain intensity and disability
therapist (the same therapist as directed the SSE group) in individual related to back pain) were each considered in the sample size
sessions. Progression of the exercises was based on specific criteria calculation, as described in the registered protocol. For the pain in-
(being able to maintain muscle contraction for 8 seconds for 30 tensity outcome, the study was powered to detect a between-group
repetitions in bilateral exercises or 20 repetitions for each limb in difference of at least 2 units30 (SD 4.5) on the 0 to 10 numerical
unilateral exercises). One of the first steps to start the MCE program pain rating scale. Statistical power of 90% and a = 0.05 were used in
was to teach the participants to maintain contraction of the trunk’s the calculation, which resulted in 40 participants per group. For the
stabilising muscles while dissociating that from movements of the low back pain-related disability, the sample size calculation showed
extremities.29,30 Movements were started in a single plane, pro- that 43 participants per group were necessary to detect a difference
gressing to multidimensional planes.30 of 10 units30 with an anticipated SD of 16. The statistical analyses
were conducted using commercial statistical softwarea. To allow for
Outcome measures some loss to follow-up, the calculated sample size of 86 was
increased to 100.
The primary outcomes were pain intensity and disability related All statistical procedures were performed according to the
to low back pain. The secondary outcomes were fear avoidance, intention-to-treat principle. First, descriptive statistics and histogram
global perceived effect and the fingertip-to-floor test. All measures inspections were used to determine whether the data were normally
were recorded at baseline (week 0), at the end of treatment (week 8) distributed. To assess between-group differences in response to
and at two follow-up points (weeks 13 and 26), except global treatment at each post-baseline time point, the mean between-group
perceived effect, which was only recorded at weeks 8, 13 and 26. difference and its associated 95% confidence interval (CI) were
calculated. The statistical analysis was conducted by a researcher who
Pain intensity was not involved in any of the phases of data collection and received
The Numerical Pain Rating Scale (0 = no pain to 10 = worst data in coded form. The statistical analyses were conducted using
imaginable pain) evaluated the mean pain intensity in the last 7 commercial statistical softwareb.
days.31 The Numerical Pain Rating Scale is responsive to changes and
the minimum clinically important difference has been nominated as Results
2.0 points among patients with chronic low back pain.13
Flow of participants through the study
Disability
The Oswestry Disability Index32 comprises ten items – each one
Between February 2017 and April 2019, we screened 158 potential
has six response options. The first response option receives 0 points
participants. Of these, 36 did not meet the inclusion criteria, 19
and describes the absence or a small amount of low back pain and
declined to participate, and three had acute health problems that
functional disability. In contrast, the sixth response option receives 5
prevented them from participating in the study (one of them suffered
points and describes extreme pain or functional disability. The sum of
an acute myocardial infarction, and two others were affected by
the points calculates the total score, the highest possible sum being
dengue fever). One hundred participants with CNSLBP were rando-
50 points. The result is transformed to a scale from 0 to 100 by
mised into two groups: SSE (n = 50) and MCE (n = 50) (Table 1). The
multiplying the final score by two. A higher score on the question-
flow of participants through the trial is shown in Figure 1. All par-
naire means more significant disability related to low back pain.
ticipants were measured at the final time point so there was no
Previous research has described 10 points as the minimum clinically
permanent loss to follow-up in the trial, as shown in Figure 1.
important difference effect of the Oswestry Disability Index.13
However, one participant declined to be evaluated at week 8 and six
Fear avoidance beliefs participants declined at week 13 (Tables 2 and 3).
The Fear Avoidance Beliefs Questionnaire (FABQ),33 consisting of
16 self-response items evaluated on a 7-point Likert scale, is scored Compliance with the study protocol
on two subscales: work (FABQ-Work) and physical activity (FABQ-
Phys). A previous study34 reported the minimum clinically important All registered outcome measures are reported in this manuscript.
difference effect of 7 points for FABQ-Work and 4 points for FABQ- Two participants did not return to receive further intervention after
Phys.
Table 1
Global perceived effect Baseline characteristics of the participants.
This measure is a single-item scale for participants to rate their
Characteristics SSE (n = 50) MCE (n = 50)
perception of clinical change on an 11-point scale ranging from
extremely worse (–5) to completely recovered (15) with the Age (yr), mean (SD) 37 (13) 37 (12)
midpoint as no modification (0).31 The minimum clinically important Gender, n (%)
female 37 (74) 31 (62)
difference effect has been nominated as 2 points for low back pain35
male 13 (26) 19 (38)
and 1.7 points for chronic low back pain.36 Weight (kg), mean (SD) 76 (17) 80 (23)
Height (cm), mean (SD) 167 (9) 168 (12)
Flexibility Body mass index (kg/m2), mean (SD) 27.5 (5.8) 28.0 (5.8)
The fingertip-to-floor test is a global stretching assessment that Pain duration (y), mean (SD) 10 (10) 9 (8)
was described and validated by Perret et al.37 The subject should Pain frequency (episodes/wk), mean (SD) 5 (2) 5 (2)
Education, n (%)
stand barefoot on a 20-cm high platform with the feet together and completed first degree 1 (2) 1 (2)
bend the torso forward as far as possible, keeping the knees, arms and incomplete high school 3 (6) 1 (2)
fingers extended for the test. The vertical distance between the tip of completed high school 8 (16) 16 (32)
the middle finger and the platform should be measured with a flex- technician 1 (2) 0 (0)
incomplete higher degree 7 (14) 8 (26)
ible measuring tape, and the measurement expressed in centimetres.
completed higher degree 25 (50) 22 (44)
The test is considered positive when the tip of the middle finger does completed postgraduate studies 4 (8) 2 (4)
not reach the platform and negative when it goes past the plat- Occupational activity, n (%)
form.22,38 It is a test that has good psychometric properties.37,38 The No manual handling at work 37 (74) 38 (76)
minimum clinically important difference has not been established but Loading weight at work 13 (26) 12 (24)

the minimum detectable change for this test was 4.5 cm.38 MCE = motor control exercise group, SSE = self-stretching exercise group.
96 Turci et al: Self-stretching and motor control exercises for back pain

Figure 1. Flow of participants through the trial.

the third day of intervention and five participants did not return to Disability
receive further intervention after the fourth day of intervention Disability improved in both groups during the intervention
(overall abandonment rate 7%). Of these seven participants, five were period; however, there was negligible difference in the effect of the
in the SSE group (abandonment rate 10%) and two were in the MCE two interventions at the end of the intervention period: MD –1 (95%
group (abandonment rate 4%). The assessor remained blinded to all CI –3 to 1). The gains achieved during the intervention period were
participants’ group allocation. All analyses followed the intention-to- sustained thereafter. However, there was negligible difference in the
treat principle. effect of the two interventions at the 13-week and 26-week follow-up
periods: MD 1 (95% CI –1 to 3) and MD 0 (95% CI –1 to 2), respectively
(Table 2). The individual participant data are presented in Table 4 on
Characteristics of the participants
the eAddenda.
The randomly allocated groups were well matched on all de-
Fear avoidance
mographic characteristics measured in the study (Table 1). They were
Scores on the FABQ-Work and FABQ-Phys domains improved in
also well matched on all the baseline scores of the outcome measures
both groups during the intervention period.; however, there was
(Table 2).
negligible difference in the effect of the two interventions at the end
of the intervention period: MD 1 (95% CI –3 to 5) and MD –1 (95% CI
Effect of the intervention –3 to 2), respectively. At the week 13 follow-up assessment, the
between-group differences for the FABQ-Work and FABQ-Phys do-
Pain intensity mains were both negligible. These estimates had confidence intervals
Although pain severity improved markedly in both groups during where the upper limit equated to the published minimum clinically
the intervention period, there was negligible difference in the effect important difference. That is, the estimate for FABQ-Work was MD 2
of the two interventions at the end of the intervention period: MD (95% CI –2 to 7); the upper limit of 7 shows that there is a small
–0.2 (95% CI –1.1 to 0.7). The gains achieved during the intervention possibility that the true average difference in effect is worthwhile in
period were largely sustained thereafter. However, there was still favour of MCE, but it is more likely that the true difference is negli-
negligible difference in the effect of the two interventions at the 13- gible. Similarly, the upper limit of 4 in the result for FABQ-Phys shows
week and 26-week follow-up periods: MD 0.0 (95% CI –1.0 to 1.1) and that there is a small possibility that the true average difference in
MD 0.2 (95% CI –0.9 to 1.2), respectively (Table 2). The individual effect is worthwhile in favour of MCE, but it is more likely that the
participant data are presented in Table 4 on the eAddenda. true difference is negligible. At the 26-week follow-up, the
 Research 97

differences were again clearly negligible (Table 2). The individual

0.2 (–0.9 to 1.2)

Week 26 minus

SSE minus MCE

participant data are presented in Table 4 on the eAddenda.

0 (–1 to 2)
2 (–2 to 6)

1 (–2 to 3)

0 (–1 to 1)
Week 0 Global perceived effect
The between-group difference in the rating of global perceived
Between-group differences

effect was negligible at the end of the intervention period: MD 0.1

(95% CI –0.5 to 0.7). The difference remained negligible at the two
SSE minus MCE
Week 13 minus

0.0 (–1.0 to 1.1)

1 (–1 to 3)
2 (–2 to 7)

1 (–2 to 4)

0 (–1 to 1)
follow-up assessment points (Table 3). The individual participant data
Week 0

are presented in Table 4 on the eAddenda.

Fingertip-to-floor test
The between-group difference in the fingertip-to-floor test was
–0.2 (–1.1 to 0.7)
SSE minus MCE
Week 8 minus

the same at all time points: MD 0 cm (95% CI –1 to 1), which was

–1 (–3 to 1)

–1 (–3 to 2)
1 (–3 to 5)

0 (–1 to 1)
Week 0

clearly negligible (Table 2). The individual participant data are pre-
sented in Table 4 on the eAddenda.

Discussion
–5.0 (2.8)
–6 (4)
–8 (9)

–6 (8)

–3 (4)
MCE
Week 26 minus

This study compared the effects of SSE with the effects of MCE on
Week 0

pain intensity, disability, fear avoidance, global perceived effect and

Shaded cells = primary outcomes. Small anomalies in subtraction are due to the effects of rounding. Higher scores reflect a worse outcome for all outcome measures in this table.

flexibility in people with CNSLBP. The effects of these two in-

–4.8 (2.7)

–6 (12)
–6 (6)

–5 (7)

0 (5)
SSE

terventions were similar enough that we can interpret that they are
equally effective for clinical purposes. This can be concluded with
great confidence for two reasons. First, the methods of the rando-
Within-group differences

–5.0 (2.4)

mised trial were very robust. The random allocation process was
–7 (4)
–8 (9)

–7 (8)

–3 (5)
MCE
Week 13 minus

protected by concealed allocation and produced very comparable

Week 0

groups at baseline. Only 7% of participants received less than the full

intervention allocated to them. The outcome assessor was blinded
–5.0 (2.6)

–6 (12)
–6 (5)

–5 (7)

–1 (5)
SSE

and all analyses followed the intention-to-treat principle. All partic-

ipants were followed up at the final assessment timepoint, with
minimal missing data at interim assessment timepoints. Second, the
–5.3 (2.6)

trial generated very precise estimates (as indicated by the very nar-
–5 (3)
–6 (9)

–5 (6)

–3 (5)
MCE
Week 8 minus

row CIs), which were able to exclude the possibility of clinically

Week 0

important differences between the two interventions. That is, the

limits of the CIs were smaller in magnitude than the nominated
–5.5 (2.0)

–5 (11)
–6 (5)

–5 (7)

–1 (6)
SSE

minimum clinically important difference.

One exception was the FABQ at the week 13 follow-up assessment.
The between-group differences for FABQ domains were both negli-
1.3 (2.3)
(n = 50)

9d (7)
4a (4)

gible but the upper limit of their CIs equalled the minimum clinically
7 (9)

7 (7)
MCE

important difference effect. That is, the estimate for FABQ-Phys was
Week 26

MD 1 (95% CI –2 to 4); the upper limit of 4 shows that there is a small

Mean (SD) of groups, mean (SD) within-group differences and mean (95% CI) between-group differences.

1.5 (2.3)
(n = 50)

11 (10)

10e (9)

possibility that the true average difference in effect is worthwhile in

5b (5)

8 (7)
SSE

favour of MCE, but it is more likely that the true difference is negli-
gible. Similarly, the upper limit of 7 in the result for FABQ-Work
1.2 (2.0)
(n = 47)

shows that there is a small possibility that the true average differ-
9a (7)
3 (3)
6 (8)

6 (6)
MCE

MCE = motor control exercise group, Phys = physical, SSE = self-stretching exercise group.

ence in effect is worthwhile in favour of MCE, but it is more likely that

Week 13

the true difference is negligible. In either case, the effect was tran-
1.3a (2.3)

sient; it was not evident at the next assessment at week 26. It is

(n = 48)

11 (10)

10a (9)
5b (5)

8 (7)
SSE

difficult to hypothesise why a treatment benefit would not be present

a
Groups

at the end of the treatment program, but then appear 1 month later,
and then be absent 2 months after that. It seems more reasonable to
0.9 (1.9)
(n = 49)

5a (4)

9c (7)
8 (8)

8 (6)
MCE

interpret that the two treatments are equally effective overall.

Week 8

Given the above, what factors might be used to help physiotherapists

decide which of these two treatments to recommend and to help people
0.8 (1.7)
(n = 50)

12 (10)

10b (8)
5a (4)

8 (7)
SSE

with CNSLBP determine which of these two treatments they prefer? The
choice of treatment should be based on the patient’s preference, as rec-
ommended by the NICE Guideline.7 Patients may have a preference
6.2 (1.8)
(n = 50)

14 (10)

12 (8)
10 (4)

13 (7)
MCE

regarding the types of exercise involved; some may prefer learning the
skills of MCE or dislike the sensation or monotony of prolonged
Week 0

stretching, whereas others may prefer the sustained stretching or dislike

6.3 (1.3)
(n = 50)

17 (11)

13 (7)

10 (9)
11 (4)

the concentration required to perform MCE. Patients may find one

SSE

intervention easier to learn and therefore may be able to move to an

independent program with fewer one-to-one sessions from the physio-
Pain intensity (0 to 10)

therapist. In shared decision-making, the therapist should also consider

Disability (0 to 100)

their own skills at delivering each intervention.

Fingertip-to-floor
Fear avoidance -

Fear avoidance -
Work (0 to 24)

Because the trial results indicate comparable effects of the two

Phys (0 to 42)

4 missing
2 missing

5 missing
1 missing

3 missing

interventions, we cannot confirm our a-priori hypothesis that the SSE

Outcomes

test (cm)

program would show greater benefits in pain intensity and disability

Table 2

than a rehabilitation program focused on MCE in patients with

d
b

e
a

CNSLBP. It is worthwhile to consider why that hypothesis was not

98 Turci et al: Self-stretching and motor control exercises for back pain

Table 3
Mean (SD) of groups and mean (95% CI) between-group differences.

Outcome Groups Between-group differences

Week 8 Week 13 Week 26 Week 8 Week 13 Week 26

SSE (n = 50) MCE (n = 49) SSE (n = 47) MCE (n = 47) SSE (n = 50) MCE (n = 49) SSE minus MCE SSE minus MCE SSE minus MCE

Global perceived 4.2 (1.4) 4.1 (1.6) 3.8 (1.7) 4.3 (1.2) 3.7 (1.8) 4.2 (1.5) 0.1 (–0.5 to 0.7) –0.5 (–1.1 to 0.1) –0.5 (–1.2 to 0.2)
effect (–5 to 5)

Higher scores indicate a better outcome.

MCE = motor control exercise group, SSE = self-stretching exercise group.

confirmed. First, because SSE involved both active stretching and Footnotes: a GPower 3.0.10, University of Kiel, Kiel, Germany.
b
active contractions and MCE involved active contractions only, we SPSS 22.0 software, SPSS Inc, Chicago, USA.
anticipated a greater beneficial effect from SSE. Conversely, the re- eAddenda: Table 4 and Appendices 1 and 2 can be found online at
sults showed exercises based on stretching and active contraction https://doi.org/10.1016/j.jphys.2023.02.016
showed the same efficacy as exercises based in contractions only, and Ethics approval: The Ethics Committee Board from the School
so no clear between-group differences were evident. Perhaps the Health Centre of the Ribeirão Preto Medical School – University of São
nature of exercise is not important other than it means the patient is Paulo (FMRP/USP) approved this study (CAAE number:
not receiving passive treatments or restricting their movement; in 55268116.9.0000.5414). All participants were informed about the
this case, equivalent doses of SSE or MCE would be expected to give procedures of this study, agreed to participate, and signed the con-
equivalent effects. In accordance with these findings, Hayden et al11 sent form.
showed no differences that meet the minimum clinically important Competing interests: Nil.
difference for pain intensity (2 out of 10)13 and functional limitation Source(s) of support: Nil.
(10 out of 100)13 between core strengthening exercises (ie, MCE) Acknowledgements: Nil.
when compared with stretching exercises in chronic low back pain. A Provenance: Not invited. Peer reviewed.
final possibility is that, as the participants themselves controlled the Correspondence: Thais Cristina Chaves, Department of Physical
progression of the stretching, this may have influenced the amount of Therapy, Federal University of São Carlos, São Carlos, Brazil. Email:
stretching obtained during the treatment. thaischaves@ufscar.br
Both exercise programs brought immediate and long-term bene-
fits for pain and disability in chronic low back pain. Given the
well-established efficacy of MCE,10–12 either exercise program can be References
recommended for the treatment of CNSLBP. 1. Ketenci A, Zure M. Pharmacological and non-pharmacological treatment ap-
Regarding treatment adherence, all rates were considered accept- proaches to chronic lumbar back pain. Turk J Phys Med Rehabil. 2021;67:1–10.
able (, 20% abandonment).39 The abandonment rate was 7% of the total https://doi.org/10.5606/tftrd.2021.8216
2. Popescu A, Lee H. Neck pain and lower back pain. Med Clin North Am.
sample, consisting of five participants (10%) in the SSE group sample
2020;104:279–292. https://doi.org/10.1016/j.mcna.2019.11.003
and two participants (4%) in the MCE group. However, 99% of the par- 3. Suzuki H, Aono S, Inoue S, Imajo Y, Nishida N, Funaba M, et al. Clinically significant
ticipants agreed to be re-evaluated at the end of the 8-week inter- changes in pain along the Pain Intensity Numerical Rating Scale in patients with
vention period, including those who left the treatment. Although 6% of chronic low back pain. PLoS One. 2020;15:e0229228. https://doi.org/10.1371/jour-
nal.pone.0229228
the participants (n = 3 in each group) did not attend assessment at week 4. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, et al.
13, all participants attended the final assessment at week 26. European guidelines for the management of chronic nonspecific low back pain. Eur
A limitation of the study was that, due to the nature of the in- Spine J. 2006;15(Suppl 2):S192–S300. https://doi.org/10.1007/s00586-006-1072-1
5. Goertz M, Thorson D, Bonsell J, Bonte B, Campbell R, Haake B, et al. Institute for
terventions administered, it was impossible to blind the participants Clinical Systems Improvement. Adult acute and subacute low back pain. Updated
and the therapist. Although not a limitation of the current trial per se, November 2012.
the lack of studies on SSE as a therapeutic modality made it difficult 6. Sheeran L, Sparkes V, Caterson B, Busse-Morris M, van Deursen R. Spinal position
sense and trunk muscle activity during sitting and standing in nonspecific chronic
to compare our results to comparable studies. Thus, future studies are low back pain: classification analysis. Spine. 2012;37:E486–E495. https://doi.org/
encourage to further explore this modality of exercises. 10.1097/BRS.0b013e31823b00ce
The results did not confirm the a priori hypothesis that the SSE 7. National Institute for Health and Care Excellence. Low back pain and sciatica in
over 16s: assessment and management (NICE Guideline NG59); 2016. www.nice.
program would have greater benefits on pain intensity and disability org.uk/guidance/ng59. Accessed December 14, 2012.
than MCE in patients with CNSLBP. As the effectiveness of MCE is well 8. Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, et al. What does best
established10–12 and the effect observed in the SSE and MCE groups practice care for musculoskeletal pain look like? Eleven consistent recommenda-
tions from high-quality clinical practice guidelines: systematic review. Br J Sports
were so similar, we recommend that either intervention could be used
Med. 2020;54:79–86. https://doi.org/10.1136/bjsports-2018-099878
for the treatment of CNSLBP and that patient (and therapist) prefer- 9. Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and
ences regarding the different exercise modalities should be considered. exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane
Database Syst Rev. 2017;4:CD011279. https://doi.org/10.1002/14651858.CD011279.
pub3
10. Saragiotto BT, Maher CG, Yamato TP, Costa LO, Costa LC, Ostelo RW, et al. Motor
What was already known on this topic: Motor control ex- control exercise for nonspecific low back pain: a Cochrane review. Spine.
ercises have well-established moderate benefits for people with 2016;41:1284–1295. https://doi.org/10.1097/BRS.0000000000001645
11. Hayden JA, Ellis J, Ogilvie R, Stewart SA, Bagg MK, Stanojevic S, et al. Some types of
chronic non-specific low back pain. Although trials have shown
exercise are more effective than others in people with chronic low back pain: a
better effects on pain and disability from self-stretching exer- network meta-analysis. J Physiother. 2021;67:252–262.
cises than from exercises based on stabilising the spine and 12. Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back
correcting postural alignment, the methodological quality of pain: a systematic review with meta-analysis. BMC Musculoskelet Disord.
those trials was not robust. 2014;15:416. https://doi.org/10.1186/1471-2474-15-416
13. Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von Korff M, et al. Interpreting
What this study adds: In people with chronic non-specific low
change scores for pain and functional status in low back pain: towards interna-
back pain, self-stretching exercises had very similar effects to tional consensus regarding minimal important change. Spine. 2008;33:90–94.
motor control exercises on pain intensity, disability, fear avoid- https://doi.org/10.1097/BRS.0b013e31815e3a10
ance, global perceived effect and flexibility up to 18 weeks 14. Oliveri M, Caltagirone C, Loriga R, Pompa MN, Versace V, Souchard P. Fast increase
beyond the end of an 8-week program. Given the established of motor cortical inhibition following postural changes in healthy subjects. Neu-
effectiveness of motor control exercises, either intervention rosci Lett. 2012;530:7–11. https://doi.org/10.1016/j.neulet.2012.09.031
15. Barroqueiro C, Morais NV. The effects of a global postural reeducation program on
could be recommended to people with chronic low back pain. an adolescent handball player with isthmic spondylolisthesis. J Bodyw Mov Ther.
2014;18:244–258. https://doi.org/10.1016/j.jbmt.2013.10.002
 Research 99

16. Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a 28. Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical
muscle stretching program using the global postural reeducation method for pa- prediction rule for determining which patients with low back pain will respond to
tients with chronic low back pain: A randomized controlled trial. Joint Bone Spine. a stabilization exercise program. Arch Phys Med Rehabil. 2005;86:1753–1762.
2015;82:272–277. https://doi.org/10.1016/j.jbspin.2015.01.015 https://doi.org/10.1016/j.apmr.2005.03.033
17. Teodori RM, Negri JR, Cruz MC, Marques AP. Global Postural Re-education: a 29. Akuthota V, Nadler SF. Core strengthening. Arch Phys Med Rehabil. 2004;85(3 Suppl
literature review. Rev Bras Fisioter. 2011;15:185–189. 1):S86–S92. https://doi.org/10.1053/j.apmr.2003.12.005
18. Di Ciaccio E, Polastri M, Bianchini E, Gasbarrini A. Herniated lumbar disc treated 30. Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship
with Global Postural Reeducation. A middle-term evaluation. Eur Rev Med Phar- to lower extremity function and injury. J Am Acad Orthop Surg. 2005;13:316–325.
macol Sci. 2012;16:1072–1077. https://doi.org/10.5435/00124635-200509000-00005
19. Ferreira GE, Barreto RG, Robinson CC, Plentz RD, Silva MF. Global Postural Reedu- 31. Costa LO, Maher CG, Latimer J, Ferreira PH, Ferreira ML, Pozzi GC, et al. Clinimetric
cation for patients with musculoskeletal conditions: a systematic review of ran- testing of three self-report outcome measures for low back pain patients in Brazil:
domized controlled trials. Braz J Phys Ther. 2016;20:194–205. https://doi.org/10. which one is the best? Spine. 2008;33:2459–2463. https://doi.org/10.1097/BRS.
1590/bjpt-rbf.2014.0153 0b013e3181849dbe
20. Lomas-Vega R, Garrido-Jaut MV, Rus A, Del-Pino-Casado R. Effectiveness of Global 32. Vigatto R, Alexandre NM, Correa Filho HR. Development of a Brazilian Portuguese
Postural Re-education for Treatment of Spinal Disorders: A Meta-analysis. Am J version of the Oswestry Disability Index: cross-cultural adaptation, reliability, and
Phys Med Rehabil. 2017;96:124–130. https://doi.org/10.1097/PHM.00000000000 validity. Spine. 2007;32:481–486. https://doi.org/10.1097/01.brs.0000255075.
00575 11496.47
21. Castagnoli C, Cecchi F, Del Canto A, Paperini A, Boni R, Pasquini G, et al. Effects in 33. Abreu AM, Faria CD, Cardoso SM, Teixeira-Salmela LF. Versão brasileira do Fear
Short and Long Term of Global Postural Reeducation (GPR) on Chronic Low Back Avoidance Beliefs Questionnaire. Cad Saude Publica. 2008;24:615–623. https://doi.
Pain: A Controlled Study with One-Year Follow-Up. Sci World J. 2015;2015:271436. org/10.1590/s0102-311x2008000300015
https://doi.org/10.1155/2015/271436 34. Monticone M, Frigau L, Vernon H, Rocca B, Giordano A, Vullo SS, et al. Reliability,
22. Bonetti F, Curti S, Mattioli S, Mugnai R, Vanti C, Violante FS, et al. Effectiveness of a responsiveness and minimal clinically important difference of the two Fear
‘Global Postural Reeducation’ program for persistent low back pain: a non- Avoidance and Beliefs Questionnaire scales in Italian subjects with chronic low
randomized controlled trial. BMC Musculoskelet Disord. 2010;11:285. https://doi. back pain undergoing multidisciplinary rehabilitation. Eur J Phys Rehabil Med.
org/10.1186/1471-2474-11-285 2020;56:600–606. https://doi.org/10.23736/S1973-9087.20.06158-4
23. Costa LO, Maher CG, Latimer J, Hodges PW, Herbert RD, Refshauge KM, et al. Motor 35. Kamper SJ, Maher CG, Mackay G. Global rating of change scales: a review of
control exercise for chronic low back pain: a randomized placebo-controlled trial. strengths and weaknesses and considerations for design. J Man Manip Ther.
Phys Ther. 2009;89:1275–1286. https://doi.org/10.2522/ptj.20090218 2009;17:163–170. https://doi.org/10.1179/jmt.2009.17.3.163
24. Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, et al. 36. Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, et al.
CONSORT 2010 Explanation and Elaboration: Updated guidelines for reporting Comparison of general exercise, motor control exercise and spinal manipulative
parallel group randomised trials. J Clin Epidemiol. 2010;63:e1–e37. https://doi.org/ therapy for chronic low back pain: A randomized trial. Pain. 2007;131(1–2):31–37.
10.1016/j.jclinepi.2010.03.004 https://doi.org/10.1016/j.pain.2006.12.008
25. Deyo RA, Dworkin SF, Amtmann D, Andersson G, Borenstein D, Carragee E, et al. 37. Perret C, Poiraudeau S, Fermanian J, Colau MM, Benhamou MA, Revel M. Validity,
Report of the NIH Task Force on research standards for chronic low back pain. reliability, and responsiveness of the fingertip-to-floor test. Arch Phys Med Rehabil.
J Pain. 2014;15:569–585. https://doi.org/10.1016/j.jpain.2014.03.005 2001;82:1566–1570. https://doi.org/10.1053/apmr.2001.26064
26. Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification- 38. Ekedahl H, Jönsson B, Frobell RB. Fingertip-to-floor test and straight leg raising
based cognitive functional therapy in patients with non-specific chronic low back test: validity, responsiveness, and predictive value in patients with acute/subacute
pain: a randomized controlled trial. Eur J Pain. 2013;17:916–928. https://doi.org/10. low back pain. Arch Phys Med Rehabil. 2012;93:2210–2215. https://doi.org/10.1016/
1002/j.1532-2149.2012.00252.x j.apmr.2012.04.020
27. Souchard PE. Fundamentos do SGA: RPG a serviço do esporte. 2nd ed. Rio de Janeiro: 39. Amico KR. Percent total attrition: a poor metric for study rigor in hosted inter-
É Realizações; 2004. vention designs. Am J Public Health. 2009;99:1567–1575.