Content uploaded by Thomaz Nogueira Burke
Author content
All content in this area was uploaded by Thomaz Nogueira Burke on Jan 06, 2018
Content may be subject to copyright.
EFFECTS OF MUSCULAR STRETCHING AND SEGMENTAL
STABILIZATION ON FUNCTIONAL DISABILITY AND PAIN
IN PATIENTS WITH CHRONIC LOW BACK PAIN:
AR
ANDOMIZED,CONTROLLED TRIAL
Fábio Renovato França, MSc, PT, Thomaz Nogueira Burke, MSc, PT, Renê Rogieri Caffaro, MSc, PT,
Luiz Armando Ramos, PT, and Amélia Pasqual Marques, PT, PhD
ABSTRACT
Objective: The purpose of this study was to compare the effects of 2 exercise programs, segmental stabilization
exercises (SSEs) and stretching of trunk and hamstrings muscles, on functional disability, pain, and activation of the
transversus abdominis muscle (TrA), in individuals with chronic low back pain.
Methods: A total of 30 participants were enrolled in this study and randomly assigned to 1 of 2 groups as a function
of intervention. In the segmental stabilization group (SS), exercises focused on the TrA and lumbar multifidus
muscles, whereas in the stretching group (ST), exercises focused on stretching the erector spinae, hamstrings, and
triceps surae. Severity of pain (visual analog scale and McGill pain questionnaire) and functional disability (Oswestry
disability questionnaire) and TrA muscle activation capacity (Pressure Biofeedback Unit, or PBU) were compared as a
function of intervention. Interventions lasted 6 weeks, and sessions happened twice a week (30 minutes each).
Analysis of variance was used for intergroup and intragroup comparisons.
Results: As compared with baseline, both treatments were effective in relieving pain and improving disability
(Pb.001). Those in the SS group had significantly higher gains for all variables. The stretching group did not
effectively activate the TrA (P=.94).
Conclusion: Both techniques improved pain and reduced disability. In this study, SS was superior to muscular stretching
for the measured variables associated with chronic low back pain. (J Manipulative Physiol Ther 2012;35:279-285)
Key Indexing Terms: Low Back Pain; Pressure; Biofeedback; Neurofeedback; Muscle Stretching Exercises;
Abdominal Muscles
Chronic low back pain (cLBP) affects over 50% of
the general population, being defined as back pain
lasting more than 12 weeks.
1
It is estimated that
over 70% of the adults have at least 1 episode of LBP over
their lifetime.
2
Prevalence is higher in young, economically
active adults in the American populations
3
; indeed, low
back pain (LBP) is the second most common reason for
absenteeism from work and one of the most common
reasons for medical consultation.
4
The etiology of LBP is complex, and the causes are not
clearly known; although some risk factors are implicated.
5
For instance, it is well established that weakness and lack of
motor control of deep trunk muscles, such as the lumbar
multifidus (LM) and transversus abdominis (TrA) muscles,
are common in LBP.
6,7
Ferreira et al
8
and Hodges et al
9
demonstrated that individuals with cLBP are more likely to
have delayed recruitment and insufficient control of the
TrA. McDonald et al
10
suggested the existence of
biomechanical, neurophysiologic, and histochemical dys-
functions in the LM of subjects with LBP, such as atrophy,
that occur in the ipsilateral painful level. Danneels et al,
11
in
an imaging study, found a reduced LM area (suggestive of
atrophy) in individuals with LBP relative to controls.
Individuals with LBP commonly present decreased
flexibility in the lumbar region, and a positive correlation
between these 2 variables was found by Thomas et al,
12
where the range of motion of the frontal, transverse, and
sagittal planes was clearly decreased. McGregor et al
13
found that cLBP patients also had reduced flexibility and
mobility in all planes of motion, relative to controls.
According to current evidence-based clinical guidelines,
exercise programs should be implemented in individuals
with nonspecificcLBP,
14
and emphasis has been put on
Physiotherapist, Department of Physical Therapy, Communi-
cation Science & Disorders, Occupational Therapy, University of
São Paulo, São Paulo, Brazil.
Submit requests for reprints to: Fábio Renovato França, MSc,
PT, Rua Cipotânea 51, Cidade Universitária 05360-160, São Paulo,
SP Brazil (e-mail: fabiojrf@hotmail.com8fabiojrf@usp.br).
Paper submitted February 23, 2011; in revised form November
21, 2011; accepted December 11, 2011.
0161-4754/$36.00
Copyright © 2012 by National University of Health Sciences.
doi:10.1016/j.jmpt.2012.04.012
279
training specific muscles of the lumbar spine involved
on segment control
15
(SSEs). Segmental stabilization
exercises aim to restore the motor control of deep trunk
muscles, such as LM and TrA. O'Sullivan et al
16
performed
a study where cLBP patients (because of spondylolysis and
spondylolisthesis) had their TrA and LM muscles trained for
10 weeks, demonstrating a significant reduction in the pain
levels and improvement in functional ability. Hides et al
17
observed that SSE was effective in reducing pain and
recurrent episodes of LBP. As for stretching, Kuukkanen and
Mälkiä
18
suggested that one of its main therapeutic goals is
to promote the normal flexibility of muscles and connective
tissues of the spine, something agreed by Martins and
Silva,
19
who reported improvement in back pain after
stretching programs.
Although the gamut of kinesitherapeutic protocols that
are potentially effective for LBP and functional disability
is impressive, comparative effectiveness studies are
lacking.
20,21
Accordingly, the aim of this study was to
compare the efficacy of 2 exercise programs, SSE and
stretching of trunk and hamstring muscles, on functional
disability, pain, and activation of the TrA muscle, in
individuals with cLBP.
METHODS
Study Design
Sample was selected from a list of patients being seen at
the Department of Orthopedics of University Hospital,
University of Sao Paulo. We included patients with LBP
for more than 3 months (pain felt between T12 and the gluteal
fold) who agreed to participate in the study. Exclusion criteria
were past history of back surgery, rheumatologic disorders,
spine infections, and spine exercise training in the 3 months
before study onset. Of 108 invited patients, 33 were assessed,
and 3 were excluded for rheumatologic disorders. Therefore,
the sample consisted of 30 patients with nonspecificcLBP.
They were randomized (random number in opaque enve-
lopes) in 1 of 2 treatment groups: the segmental stabilization
group (SS) and the stretching group (ST).
Subjects
This study was approved by the ethics committee of the
University Hospital (Protocol 700/06) and of the School of
Medicine (Protocol 1249/06), University of Sao Paulo, and
the study was registered at clinicaltrials.gov (registration
number: NCT01124201). All participants gave their
informed consent before participation. All patients had
radiologic examination before the study (Fig 1).
Exercise Programs
Interventions were conducted over 6 weeks, twice per
week, lasting 30 minutes each. Sessions were supervised by
the investigator, and participants were instructed to report
any adverse event, related or not to exercises. Participants
were instructed not to participate in any other physical
program during the study as well as not to exercise while at
home. In the SS, exercises focused on the TrA and LM
muscles according to the protocol proposed by Richardson
et al.
7,22
In the ST group, stretching of erector spinae,
hamstring, and triceps surae muscles and connective tissues
posterior to column were conducted
23
(Table 1).
Tests and Measurements
Participants were assessed at baseline and at the end of
study treatment by an investigator (physical therapist)
blinded to the randomization, severity of pain, functional
disability, and TrA activation capacity.
Pain
Pain was assessed using a visual analog scale (VAS) and
the McGill pain questionnaire.
24
The VAS consists of a 10-
cm line, with the left extremity indicating “no pain”and the
right extremity indicating “unbearable pain.”Participants
were asked to use the scale to indicate their current level of
pain. Higher values suggest more intense pain. This
instrument showed good reproducibility in the assessment
of pain.
25
The McGill pain questionnaire consists of a list of
78 pain descriptors organized into 4 major classes (sensory,
affective, evaluative, and miscellaneous) and 20 subclasses,
each made up of at least 2 and at most 6 words, to which are
assigned intensity values. The McGill pain questionnaire
was adapted and validated to Portuguese by Varoli and
Pedrazzi.
24
Functional Disability
Functional disability was estimated by the Oswestry
disability questionnaire, a functional scale assessing the
impact of LBP on daily activities. This instrument was
validated for the Portuguese language with excellent
psychometric properties and high reliability for the
Brazilian population.
26
The score is calculated by the
addition of the values assigned for each of the 10 individual
questions and is used to categorize disability in the
following: mild or no disability (0%-20%), moderate
disability (21%-40%), severe disability (41%-60%), inca-
pacity (61%-80%), restricted to bed (81%-100%).
Transversus Abdominis Activation Capacity
Transversus abdominis muscle activation capacity was
assessed by using the Pressure Biofeedback Unit (PBU;
Chattanooga Group—Australia), a reliable tool for analysis
of this muscle contraction.
27
The PBU consists of a
combined gauge/inflation bulb connected to a pressure cell.
It is a simple device that registers changing pressure in an
280 Journal of Manipulative and Physiological TherapeuticsFrança et al
May 2012Stretching and Stabilization
air-filled pressure cell allowing body movement, especially
spinal movement, to be detected during exercise. The gauge
contains 16.7 × 24 cm of inelastic material. The pressure
cell measures from 0 to 200 mm Hg, with a precision of
2 mm Hg. Changes in body position modify the pressure,
which are registered by the sphygmomanometer.
28
The
device was placed on the TrA (above the anterior superior
iliac spines) while participants were in ventral decubitus
over a rigid surface. The depression of the abdominal
muscles over the spinal cord typically decreases the
pressureby4to10mmHg.
15
Before requesting
individuals to contract the muscle, the device was inflated
to a pressure of 70 mm Hg. The instruction given was to
draw the lower stomach gently off the pressure sensor
without moving the back or the hip and to sustain it for
10 seconds, measured by a stop watch.
Statistical Analysis
Sample size was calculated assuming a power of 80% to
detect a 30% improvement in pain (VAS), with a standard
deviation of 2.5 points and a significance level of 5%. The
required sample would be 12 patients per group.
The relative gain with treatment was calculated with the
following equation:
RGi=Baselinei−Endi
ðÞ
Endi−Min variableðÞ
× 100
One-way analysis of variance was used for intergroup and
intragroup comparisons. For TrA activation, the binomial test
was used. Analyses were done using Minitab 14 and 15
(Minitab Inc., State College, PA) for Windows. Significance
level was established in 5%.
RESULTS
Sample Characterization
Table 2 displays the demographic data as a function of
treatment group. No significant differences were seen for
age, weight, and height.
Assessed for eligibility (n = 33)
Excluded (n = 3)
♦Rheumatologic disorders (n = 3)
Analysed (n = 15)
Allocated to SS (n = 15)
♦Received allocated intervention (n = 15)
Allocated to ST (n = 15)
♦Received allocated intervention (n = 15)
Analysed (n = 15)
Allocation
Analysis
Randomized (n = 30)
Enrollment
Contacted by phone (n = 108)
Fig 1. Flow diagram for the study.
281França et alJournal of Manipulative and Physiological Therapeutics
Stretching and StabilizationVolume 35, Number 4
Pre- to Posttreatment Results
Data from the SS training group are shown on Table 3. All
variables significantly improved with treatment (Pb.001).
Highest relative gain was for pain (99%). Contraction of
the TrA improved by 48.3%.
Table 4 displays the results for the ST group. All
variables significantly improved with treatment (Pb.001),
with the exception of TrA contraction (P=.94). Highest
relative gain was for pain (56%). Functional disability
improved by 52%.
Intragroup Comparisons
Figure 2 contrasts the results seen in-between groups.
The SS group yielded significantly higher gains in all
variables when compared with ST group.
DISCUSSION
The aim of this study was to compare the efficacy of SS
and ST exercises in the relief of cLBP symptoms. Both
treatments were effective in relieving pain and in decreasing
functional disability, but the SS group had more significant
improvements, and only the SS treatment improved TrA
muscle activation.
The PBU test has been validated by electromyography
7
and imaging,
9
gold-standard measurements of TrA perfor-
mance. These tests demonstrated that individuals with LBP
have impairment in their ability to depress the abdominal
wall. Hides et al
29
suggest that the TrA is important in
sustaining the spine, also suggesting that its conditioning is
accompanied by functional improvement.
Ferreira et al
8
and Teyhen et al
30
also suggested that TrA
exercises improve recruitment in individuals with LBP.
According to Richardson et al,
7
normal PBU responses
range from −4to−10 mm Hg; for Hodges et al,
9
mean
normal values are approximately −5.82 mm Hg.
The SS group trained the TrA and LM muscles. On
average, participants had optimal depression of the
abdominal wall, as measured by the PBU, with a relative
gain of 48.3%. These values ranged from −0.67 mm Hg
(inadequate contraction of TrA) before treatment to −5.33
mm Hg after therapy (optimal capacity of contraction of
TrA), and values are similar to those obtained by Cairms
et al.
31
For individuals in the ST group, there were no
significant improvements in the ability to activate the TrA.
All participants in this study experienced pain for at least
1 year. The SS technique yielded important improvements
(99% when measured by the VAS and 90% by the McGill
questionnaire); functional disability improved by 90%. Our
findings are supported by other studies,
16,17
in which SS
translated into pain and functional capacity improvements.
The ST group also had meaningful reductions in pain
intensity, with a decrease of 49% and 42%, respectively, in
the VAS and in the McGill pain questionnaire. The impact of
stretching exercises on flexibility has been investigated.
32
The increased range of motion is directly linked to decreased
pain levels, improvement in the viscoelastic properties of
tendon,
33,34
and increasing of the number of sarcomeres in
series of muscle fiber.
35,36
The superior results of the SS group may be explained
by the fact that this technique addressed 2 muscles
primarily affected by LBP. Hides et al
6
suggested the
existence of selective atrophy of the LM after a first
episode of back pain, unlikely to revert without specific
training. The consequent decreased muscular stability
predisposed to further episodes of LBP. In individuals
with LBP, the TrA has decreased anticipatory capacity,
meaning that it has reduced segmental protective
function.
9
Richardson et al
7
suggested that both muscles
are primary stabilizers of the lumbar segment, minimizing
compressive forces on spinal structures.
Several studies suggest that passive methods do not
translate into persistentchanges in musculoskeletal structures
because they do not involve active learning
37
and conscious
Table 2. Patient demographic data and duration of pain,
according to group
Features
SS group
(n = 15)
ST group
(n = 15) P
Age (y), mean (SD) 42.07 (8.15) 41.53 (4.41) .823
Weight (kg), mean (SD) 74.61 (16.26) 80.54 (18.60) .360
Height (cm), mean (SD) 1.67 (0.11) 1.61 (0.09) .113
Pain, n (%)
12-24 mo 4 (26.66) 5 (33.33)
N24 mo 11 (73.44) 10 (66.6)
Pvalues are for ttest.
Table 1. Treatment protocol in the SS and ST groups
Segmental stabilization
17,22
Strengthening of the
TrA and LM
Exercises for the TrA in 4 point kneeling
Exercises for the TrA in dorsal decubitus
with flexed knees
Exercises for the LM in ventral decubitus
Cocontraction of the TrA and LM in the
upright position
3 series of 15 repetitions were done for each
exercise
Stretching
23
Stretching of the ES,
HS, and TS
Stretching of the ES in dorsal decubitus,
with flexed hips and knees
Stretching of the HS and TS in dorsal
decubitus, with forced flexion of 1 limb at
atimewithassistanceofthephysical
therapist
Stretching of the ES with the patient sitting
on heels, flexed trunk with the abdomen
resting on the front of the thighs
Global stretching of the posterior muscular
chain (TS, HS, ES)
2 series of 4 minutes were performed, with 1
minute of resting interval.
ES, erector spinae; HS, hamstring; TS, triceps surae.
282 Journal of Manipulative and Physiological TherapeuticsFrança et al
May 2012Stretching and Stabilization
postural execution
38
of coordinated body movements that
avoid the reappearance of LBP.
4
This may explain the fact of
a more substantial improvement in the SS group, which used
techniques of motor control, with substantial improvement in
the ability of TrA muscle contraction.
Cairms et al
31
found that individuals with history but not
current LBP have impairments in TrA recruitment.
Accordingly, pain remission does not necessarily translate
into improved muscle activation capacity. Hides et al
6
found that even after pain remission in patients with LBP,
proper deep muscle reestablishment often did not happen
and that specific physical therapy focusing on these muscles
was often necessary. Snijders et al
39
postulated that the
cocontraction of the TrA and LM muscles is the basis of the
lumbosacral biomechanic stability and that these muscles
act by reducing the compressive overloads, attenuating or
eradicating pain perception.
It may be suggested that, based on our findings, both
exercise protocols may be of clinical utility in the
improvement of cLBP. The specific training of the TrA
muscle translated into better results, suggesting that motor
control training should be included in rehabilitation
protocols of chronic nonspecific LBP. Studies have
shown that strengthening and endurance exercises for
nonspecificLBP
40
and neck pain
41
areeffectivein
reducing pain and improving function.
The results of this study will help in the design of an
exercise program for cLBP. Because most studies use more
than 1 resource (ultrasound, stretching, electrical stimula-
tion, and strengthening exercises), this study took care to
use them individually and, therefore, identify only a
program to reduce the symptoms and what should be the
most efficient. The cost of treatment is low compared with
more invasive treatments, and enforcement may be easier to
accomplish. In addition, patients, after training, can perform
the exercises at home.
LIMITATIONS
This study has some limitations that need to be
addressed. A more specific analysis of the LM and TrA
muscles using ultrasound imaging or electromyography
was not performed. A control group without treatment was
not included in this study; thus, there may be bias in the
results. A follow-up of at least 6 months was not performed.
Because of the small sample size and potential methodo-
logical bias of this study, results should be considered with
caution. In future studies, selection of participants and
evaluation methods should be refined.
CONCLUSIONS
Muscular stretching and SSE decreased pain and
functional disability in study participants with cLBP.
Table 3. Pain, functional disability, and contraction of TrA in those
receiving SS, at the pretreatment and posttreatment assessments
SS group (n = 15) Relative
gain PPretreat Posttreat
Pain-VAS (0-10)
#
5.94 (1.56) 0.06 (0.16) 99% b.001 ⁎
Pain-McGill (0-67)
#
35.00 (7.76) 3.20 (4.00) 92% b.001 ⁎
Sensory (0-34)
#
18.20 (4.43) 1.73 (2.99) 93% b.001 ⁎
Affective (0-17)
#
8.07 (2.43) 0.33 (0.62) 97% b.001 ⁎
Functional disability
(0-45)
#
17.07 (3.99) 1.80 (1.26) 90% b.001 ⁎
Contraction of
TrA-PBU (4 to
−10 mm Hg)
#
−0.67 (1.95) −5.33 (1.23) 48.32% b.001 ⁎
Data are expressed as mean (SD). Pretreat indicates before treatment;
posttreat, immediately after treatment.
⁎Statistically significant difference comparing pretreatment and
posttreatment.
#
Normal range.
Table 4. Pain, functional disability, and contraction of TrA in those
receiving ST, at the pretreatment and posttreatment assessments
ST group (n = 15) Relative
gain PPretreat Posttreat
Pain-VAS (0-10)
#
6.35 (1.51) 3.15 (1.20) 49% b.001 ⁎
Pain-McGill (0-67)
#
33.93 (6.39) 19.07 (5.60) 42% b.001 ⁎
Sensory (0-34)
#
18.53 (3.58) 10.87 (3.98) 37% b.001 ⁎
Affective (0-17)
#
7.93 (3.10) 3.33 (1.72) 56% b.001 ⁎
Functional
disability–
Oswestry (0-45)
#
18.73 (3.61) 9.20 (4.09) 52% b.001 ⁎
Contraction of
TrA-PBU 4 to
−10 mm Hg)
#
−0.13 (1.41) −0.80 (1.47) 6.56% .94
Data are expressed as mean (SD). Pretreat indicates before treatment;
posttreat, immediately after treatment.
⁎Statistically significant difference comparing pretreatment and
posttreatment.
#
Normal range.
40
35
30
25
20
15
10
5
0
Pain-VAS (cm) Pain-McGill Oswestry PBU (mmHg)
ST
SS
*
*
*
*
Difference before and after treatment
Fig 2. Difference before and after treatment in each group. Data
are expressed as mean ± SD. *Statistically significant difference
vs Stretching group (P b.001).
283França et alJournal of Manipulative and Physiological Therapeutics
Stretching and StabilizationVolume 35, Number 4
Segmental stabilization but not stretching improved TrA
muscle activation capacity. Segmental stabilization seemed
to be more effective than stretching for cLBP in this study.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
This study received Public Financial Support of: State of
São Paulo Research Foundation (FAPESP). No funding
conflicts of interest were reported for this study.
REFERENCES
1. Rozemberg S. Chronic low back pain: definition and
treatment. Rev Prat 2008;15:265-72.
2. Lawrence JP, Greene HS, Grauner JN. Back pain in athletes.
J Am Acad Orthop Surg 2006;14:726-35.
3. De Vitta A. A lombalgia e suas relações com o tipo deocupação
com a idade e o sexo. Rev Bras Fisioter 1996;1:67-72.
4. Ebenbichler GR, Oddsson LIE, Kollmitzer J, Erim Z.
Sensory-motor control of the lower back: implications for
rehabilitation. Med Sci Sports Exerc 2001;33:1889-98.
5. Demirel R, Ucok K, Kavuncu V, Gecicid O, Evcike D,
Dundar U, et al. Effects of balneotherapy with exercise in
patients with low back pain. J Back Musculoskelet Rehabil
2008;21:263-72.
6. Hides JA, Richardson CA, Jull GA. Multifidus muscle
recovery is not automatic following resolution of acute first-
episode low back pain. Spine 1996;21:2763-9.
7. Richardson C, Hodges P, Hides J. Therapeutic exercise for
lumbopelvic stabilization. A motor control approach for the
treatment and prevention of low back pain. 2nd ed.
Queensland, Australia: Churchill Livingstone; 2004.
8. Ferreira PH, Ferreira ML, Maher CG, Refshauge K, Herbert
R, Hodges PW. Changes in recruitment of transversus
abdominis correlate with disability in people with chronic
low back pain. Br J Sports Med 2010;44:1166-72.
9. Hodges PW, Richardson CA. Inefficient muscular stabiliza-
tion of the lumbar spine associated with low back pain: a
motor control evaluation of transversus abdominis. Spine
1996;21:2640-50.
10. McDonald DA, Moseley GL, Hodges PW. The lumbar
multifidus: does the evidence support clinical beliefs? Man
Ther 2006;11:254-63.
11. Danneels LA, Vanderstraeten GG, Cambier DC, Witvrouw
EE, Cuyper HJD. Computed tomography of trunk muscles in
chronic low back patients and healthy control subjects. Eur
Spine J 2000;9:266-72.
12. Thomas E, Silman A, Papageorgiou A, Macfarlane G, Croft P.
Association between measures of spinal mobility and low
back pain. An analysis of new attenders in primary care. Spine
1998;23:343-7.
13. McGregor A, McCarthy I, Hughes S. Motion characteristics
of normal subjects and people with low back pain. Physiother
1995;81:632-7.
14. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-
Moffett J, Kovacs F, et al. Chapter 4. European guidelines for
the management of chronic nonspecific low back pain. Eur
Spine J 2006;15(Suppl 2):S192-300.
15. Richardson C, Jull G, Hodges PW, Hides JA. Therapeutic
exercise for spinal segmental stabilization in low back pain.
1st ed. Queensland, Australia: Churchill Livingstone; 1999.
16. O'Sullivan PB, Twomey LT, Allison GT. Evaluation of
specific stabilizing exercise in the treatment of chronic low
back pain with radiologic diagnosis of spondylolysis or
spondylolisthesis. Spine 1997;22:2959-67.
17. Hides JA, Jull GA, Richardson CA. Long-term effects of
specific stabilizing exercises for first-episode low back pain.
Spine 2001;26:E243-8.
18. Kuukkanen T, Mälkiä E. Effects of a three-month therapeutic
exercise programme on flexibility in subjects with low back
pain. Physiother Res Int 2000;5:46-60.
19. Martins R, Silva JLP. Tratamento da lombalgia e dor pélvica
posterior na gestação por um método de exercícios. Rev Bras
Ginecol Obstet 2005;27:275-82.
20. Liddle SD, Baxter GD, Gracey JH. Exercise and chronic low
back pain: what works? Pain 2004;107:176-90.
21. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Meta-
analysis: exercise therapy for nonspecific low back pain. Ann
Intern Med 2005;142:765-75.
22. Richardson C, Jull G. Muscle control–pain control. What
exercises would you prescribe? Man Ther 1995;1:2-10.
23. Kisner C, Colby L. Therapeutic exercise: foundations and
techniques. 5th ed. Philadelphia, PA: F.A. Davis Company;
2007.
24. Varoli FK, Pedrazzi V. Adapted version of the McGill pain
questionnaire to Brazilian Portuguese. Braz Dent J 2006;17:
328-35.
25. Dixon JS, Bird HA. Reproducibility along a 10-cm vertical
visual analogue scale. Ann Rheum Dis 1981;40:87-9.
26. Vigatto R, Alexandre NM, Filho HR. Development of a
Brazilian Portuguese version of the Oswestry Disability
Index. Spine 2007;32:481-6.
27. Costa LOP, Costa LCM, Cançado RL, Oliveira WM,
Ferreira PH. Reliability analysis of palpation test and
biofeedback pressoric unit on the activation of transversus
abdominis muscle in normal individuals. Acta Fisiatr 2004;
11:101-5.
28. Anonymous. Stabilizer pressure biofeedback. Operating
instructions. Brisbane: Chattanooga Pacific; 2002.
29. Hides J, Wilson S, Stanton W, McMahon S, Keto H,
McMahon K, et al. An MRI investigation into the function
of the transversus abdominis muscle during “drawing-in”of
the abdominal wall. Spine 2006;31:175-8.
30. Teyhen DS, Miltenberger CE, Deiters HM, Del Toro YM,
Pulliam JN, Childs JD, et al. The use of ultrasound imaging of
the abdominal drawing-in maneuver in subjects with low back
pain. J Orthop Sports Phys Ther 2005;35:346-55.
31. Cairms MC, Harrison K, Wright C. Pressure biofeedback: a
useful tool in the quantification of abdominal muscular
dysfunction? Physiother 2000;86:127-38.
32. Halbertsma JPK, Mulder I, Goeken LNH, Eisma WH.
Repeated passive stretching: acute effect on the passive
muscle moment and extensibility of short hamstrings. Arch
Phys Med Rehabil 1999;80:407-14.
33. Taylor DC, Brooks DE, Ryan JB. Viscoelastic characteristics
of muscle: passive stretching versus muscular contractions.
Med Sci Sports Exerc 1997:1619-24.
Practical Applications
•Muscular stretching and SSE improved pain and
reduced disability in patients with cLBP.
•Stretching exercises did not improve motor control of
TrA, even improving pain and functional capacity.
•Active exercises were more effective than passive
in pain and functional capacity of LBP patients.
284 Journal of Manipulative and Physiological TherapeuticsFrança et al
May 2012Stretching and Stabilization
34. Ferreira GNT, Teixeira-Salmela LF, Guimarães CQ. Gains in
flexibility related to measures of muscular performance:
impact of flexibility on muscular performance. Clin J Sport
Med 2007;17:276-81.
35. Chan SP, Hong Y, Robinson PD. Flexibility and passive
resistance of hamstrings of young adults using two different
static stretching protocols. Scand J Med Sci Sports 2001;11:
81-6.
36. Coutinho EL, Gomes ARS, França CN, Oishi J, Salvini
TF. Effect of passive stretching on immobilized soleus
muscle fiber morphology. Braz J Med Biol Res 2004;37:
1853-61.
37. Gottlieb G, Corcos D, Jaric S, Agarwal GC. Practice
improves even simplest movements. Exp Brain Res 1988;
73:436-40.
38. Patla A, Ishac M, Winter D. Anticipatory control of center of
mass and joint stability during voluntary arm movement from
a standing posture: interplay between active and passive
control. Exp Brain Res 2002;143:318-27.
39. Snijders CJ, Ribbers MT, de Bakker HV, Stoeckart R, Stam HJ.
EMG recordings of abdominal and back muscles in various
standing postures: validation of a biomechanical model on
sacroiliac joint stability. J Eletromyogr Kinesiol 1998;8:205-14.
40. Slade SC, Keating JL. Trunk-strengthening exercises for
chronic low back pain: a systematic review. J Manipulative
Physiol Ther 2006;29:163-73.
41. Sihawong R, Janwantanakul P, Sitthipornvorakul E, Pensri P.
Exercise therapy for office workers with nonspecific neck
pain: a systematic review. J Manipulative Physiol Ther 2011;
34:62-71.
285França et alJournal of Manipulative and Physiological Therapeutics
Stretching and StabilizationVolume 35, Number 4
