International Journal of

Environmental Research
and Public Health

Article
Tolerability and Muscle Activity of Core Muscle
Exercises in Chronic Low-back Pain
Joaquín Calatayud 1,2 , Adrian Escriche-Escuder 3 , Carlos Cruz-Montecinos 4 ,
Lars L. Andersen 5,6 , Sofía Pérez-Alenda 2,7 , Ramón Aiguadé 8 and José Casaña 1, *
1 Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of
Valencia, 46010 Valencia, Spain; joaquin.calatayud@uv.es
2 Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain; sofia.perez-alenda@uv.es
3 Department of Physiotherapy, University of Malaga, 29071 Malaga, Spain; adrianescriche@gmail.com
4 Laboratory of Clinical Biomechanics, Department of Physical Therapy, Faculty of Medicine, University of
Chile, Santiago 8380453, Chile; ccmkine@gmail.com
5 National Research Centre for the Working Environment, 2100 Copenhagen, Denmark; lla@nrcwe.dk
6 Sport Sciences, Department of Health Science and Technology, Aalborg University, 9100 Aalborg, Denmark
7 Haemostasis and Thrombosis Unit, Universitary and Polytechnic Hospital La Fe, 46026 Valencia, Spain
8 Department of Nursing and Physiotherapy, University of Lleida, 25003 Lleida, Spain; raiguade@aiguade.com
* Correspondence: jose.casana@uv.es; Tel.: +34-656437371




Received: 6 August 2019; Accepted: 18 September 2019; Published: 20 September 2019


Abstract: Most of the studies evaluating core muscle activity during exercises have been conducted
with healthy participants. The objective of this study was to compare core muscle activity and
tolerability of a variety of dynamic and isometric exercises in patients with non-specific low back pain
(NSLBP). 13 outpatients (average age 52 years; all with standing or walking work in their current or
latest job) performed 3 consecutive repetitions at 15-repetition maximum during different exercises in
random order. Surface electromyography was recorded for the rectus abdominis; external oblique
and lumbar erector spinae. Patients rated tolerability of each exercise on a 5-point scale. The front
plank with brace; front plank and modified curl-up can be considered the most effective exercises in
activating the rectus abdominis; with a median normalized EMG (nEMG) value of 48% (34–61%), 46%
(26–61%) and 50% (28–65%), respectively. The front plank with brace can be considered the most
effective exercise in activating the external oblique; with a nEMG of 77% (60–97%). The squat and
bird-dog exercises are especially effective in activing the lumbar erector spinae; with nEMG of 40%
(24–87%) and 29% (27–46%), respectively. All the exercises were well tolerated; except for the lateral
plank that was mostly non-tolerated. In conclusion; the present study provides a variety of dynamic
and isometric exercises; where muscle activity values and tolerability can be used as guide to design
evidence-based exercise programs for outpatients with NSCLBP.

Keywords: bridging; electromyography; plank; squat; trunk

1. Introduction
Low back pain (LBP) is a major public health challenge and a socioeconomic burden worldwide [1].
LBP is the leading cause of disability in people under 45, generating the greatest economic
health-expenditure in the population between 20 and 50 [2] and increasing the risk of long-term
sickness absence from work [3,4]. In most cases, people recover spontaneously from the pain regardless
of the treatment, however many suffer one or more episodes of recurrence. Pain can be disabling
and persist in about 20–30% of cases, limiting activity and functional capacity and deteriorating the
quality of life [2]. Part of this persistent and disabling LBP constitutes the non-specific chronic low back
pain (NSCLBP), described as pain in the area between the last rib and the gluteal folds that persists

Int. J. Environ. Res. Public Health 2019, 16, 3509; doi:10.3390/ijerph16193509 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2019, 16, 3509 2 of 11

for at least 12 weeks without obvious radiological signs of abnormality or another known possible
cause [5–7].
Active exercise for low-back pain is one of the most prescribed treatments [8]. Particularly, specific
training of the low back and abdominal muscles or “core stability training” have become a popular
treatment [9]. Core stability training involves activating deep and superficial spinal muscles [10].
Exercises providing proper activity (neural drive) have been recommended to train core muscles in
NSCLBP [11]. However, most of the studies evaluating core muscle activity during different exercises
have been conducted with healthy people and thus exercise selection in rehabilitative programs has
been usually based in these data [12]. This limits proper design of therapeutic programs, because
patients with NSCLBP have shown altered core activity patterns compared to healthy peers [13,14].
To target the core muscles, both isometric and dynamic exercises can be used. However, most
of the exercise evaluation studies with electromyography (EMG) in NSCLBP patients have used
isometric contractions, underestimating the potential benefits and specific adaptations of dynamic
exercises. Moreover, in case of using dynamic exercises in patients with NSCLBP, absolute loads
were used, making individualization with a relative intensity for each patient difficult [5,15]. While
some isometric exercises provide adequate resistance to enhance core stiffness [16], dynamic exercises
provide less angle-specific adaptations, greater dynamic muscle strength gains [17] and can be
easily manipulated to gradually increase intensity as the phases of rehabilitation progress. This fact
facilitates dose-individualization and may be especially relevant in advanced rehabilitative stages where
progressive neuromuscular challenge must be achieved to further enhance adaptations. Furthermore,
dynamic exercises are more related to daily life activities and have shown promising core EMG activity,
at least in healthy subjects [18]. For instance, a previous study found that the squat exercise generally
provided greater longissimus and multifidus activity than other typical exercises performed with a
stability ball in healthy subjects [18]. However, studies evaluating core EMG values during different
dynamic and isometric exercises in patients with NSCLBP are scarce.
In addition, patient tolerability of these exercises (together with the EMG values) could provide
further insight for a proper exercise selection in therapeutic programs. However, no previous studies
have provided such knowledge. Thus, the purpose of this cross-sectional study was to evaluate
core muscle activity and tolerability during a variety of exercises (including the most used isometric
and other promising dynamic exercises) in patients with NSCLBP, in an effort to help in clinical
decision-making. We hypothesized that the brace front plank, the torso-twist, and the squat would
provide the highest rectus abdominis, external oblique and erector spinae activity, respectively.

2. Material and Methods

2.1. Subjects
Outpatients 18 years or older, diagnosed with non-specific chronic low back pain and visiting a
local hospital during the year of 2017 were considered candidates for the present study and were asked
to participate. Inclusion criteria was as follows: non-specific low back pain present for at least the last
3 months, age between 18–75 years old, being referred to hospital rehabilitation by a physician, having
the capacity of understanding the exercises. Participants were excluded if they had undergone spine
surgery, if they were taking any medication at the moment the study was conducted or if they had any
medical condition in which exercise was contraindicated. A total of 13 patients with NSLBP (4 men
and 9 women) voluntarily participated in the study, which was performed during November 2017.
All participants were informed about the purpose and content of the investigation. Written informed
consent was obtained from all individual participants included in the study. The study conformed to
The Declaration of Helsinki and was approved by the Local Ethical Committee (H1496152714192).
Int. J. Environ. Res. Public Health 2019, 16, 3509 3 of 11

2.2. Procedures
All the participants had 3 familiarization sessions, with 48h rest between sessions. During the
first familiarization session, height (IP0955, Invicta Plastics Limited, Leicester, England) and body
mass (Tanita model BF- 350, Tokyo, Japan) were obtained. During the last familiarization session,
elastic resistance used during each dynamic exercise was measured for the subsequent experimental
measurements. In addition, subjects replied to the following question: “How would you generally
describe your physical activity in your main job?” participants replied on a 4-point scale: (1) Seated work,
(2) Standing or walking work that is not strenuous, (3) Standing or walking work with lifting tasks,
(4) Heavy and fast strenuous work.
After the third familiarization session, participants had 48h of rest from the specific exercises
before starting the experimental session.
Before the experimental session, several restrictions were imposed on the volunteers: no food,
drinks, or stimulants (e.g., caffeine) to be consumed two hours before the sessions and no physical
activity more intense than daily activities 24 h before the exercises. All measurements were made by
the same two investigators and were conducted in the same facility (a primary care center). This article
adheres to the STROBE guidelines [19].
Before starting with the EMG protocol, an 11-point numerical rating scale, where 0 = “no pain” and
10 = “the worst possible pain”, was used to assess subject’s perception of LBP intensity during the last
week. After that, the EMG protocol started with the preparation of subjects’ skin, followed by electrode
placement, maximum voluntary isometric contraction (MVIC) collection and exercise performance.
Hair was removed from the skin overlying the muscles of interest and the skin was then cleaned
by rubbing with cotton wool dipped in alcohol for the subsequent electrode placement. Electrodes
were placed according to established recommendations [20] on the rectus abdominis, external oblique
and lumbar erector spinae, on the dominant side of the body. Specifically: electrodes for the rectus
abdominis were located 2 cm lateral and across from the umbilicus over the muscle belly; electrodes
for the external oblique were placed lateral to the rectus abdominis and directly above the anterior
superior iliac spine, halfway between the crest and the ribs at a slightly oblique angle; electrodes for
the lumbar erector spinae were placed 2 cm from the spine over the muscle mass, with the iliac crest
used to determine the L-3 vertebra.
Pre-gelled bipolar silver/silver chloride surface electrodes (Blue Sensor M-00-S, Medicotest,
Olstykke, Denmark) were placed with an inter-electrode distance of 2 cm. The reference electrode was
placed between the active electrodes, approximately 10 cm away from each muscle, according to the
manufacturer’s specifications. All signals were acquired at a sampling frequency of 1 kHz, amplified
and converted from analog to digital. To acquire the surface EMG signals produced during exercise,
an ME6000P8 (Mega Electronics, Ltd., Kuopio, Finland) biosignal conditioner was used. All records
of myoelectrical activity (in microvolts) were stored on a hard drive for later analysis. Prior to the
exercise performance described below, two MVIC of 5 secs were performed for each muscle and the
trial with the highest EMG was selected. Participants performed a non-maximal practice trial to ensure
that they understood the task. They were asked to exert progressive contraction during 2 s and 3 s of
maximal contraction without reaching a pain intensity greater than 4 of 10. Verbal encouragement
was provided to motivate all participants to achieve maximal muscle activity. MVICs were based on
standardized muscle testing procedures [21] for the (1) rectus abdominis, (2) external oblique and (3)
lumbar erector spinae. Specifically, (1) curling up at 40 degrees with arms on the chest and pressing
against the resistance with the participant lying on the exercise mat and feet flat on the floor, (2) curling
up at 40 degrees with arms on the chest and pressing against the resistance in an oblique direction
with the participant lying on the exercise mat, with the feet flat on the floor and the knees bent at
90 degrees, and (3) trunk extension with the participant lying on a bench and pelvis fixated, the trunk
was extended against the resistance.
Each subject performed the following nine different exercises (Figure 1), randomly assigned and
with 1-min rest interval: torso-twist (from a standing position with feet shoulder-width apart and the
 mat and feet flat on the floor, 2) curling up at 40 degrees with arms on the chest and pressing
against the resistance in an oblique direction with the participant lying on the exercise mat, with the
feet flat on the floor and the knees bent at 90 degrees, and 3) trunk extension with the participant
lying on a bench and pelvis fixated, the trunk was extended against the resistance.
Each subject
Int. J. Environ. performed
Res. Public the3509
Health 2019, 16, following nine different exercises (Figure 1), randomly assigned 4 of 11
and with 1-min rest interval: torso-twist (from a standing position with feet shoulder-width apart
and the elastic band attached to the left feet, with arms positioned horizontally and extended, the
elastic
patients band
hadattached
to twist to thetorso
their left feet,
fromwith
left arms positioned
to right horizontally
while maintaining and
feet, extended,
legs, and hipthe patients
stationary);
had to twist their torso from left to right while maintaining feet, legs,
squat (from standing position with feet shoulder-width apart, with the band underneath the and hip stationary); squat (from
feet
standing position with feet shoulder-width apart, with the band
and the other extreme over the shoulders with both hands gripping the corresponding loop, underneath the feet and the other
extreme
patientsoverwerethe shoulders
asked to squat with both
until 90°hands
of kneegripping
flexion);thebird-dog
corresponding
(from aloop, patientsposition,
quadruped were asked to
lifting
squat until 90 ◦ of knee flexion); bird-dog (from a quadruped position, lifting a leg and the contralateral
a leg and the contralateral arm so that the hip and knee were fully extended and the shoulder
arm so that
flexed); the hip curl-up
modified and knee(lyingwere fully
with extended
the back andon thethe shoulder
floor, withflexed);
one modified
knee flexed curl-up
and (lying
hands
with
underneath the low back, the patients have to slowly raise the chest, shoulders and head); have
the back on the floor, with one knee flexed and hands underneath the low back, the patients front
to slowly raise the chest, shoulders and head); front plank (prone
plank (prone position with the elbows flexed to 90° and knees fully extended, only with the position with the elbows flexed
to 90◦ andand
forearms knees fully
toes extended,
in contact withonlythewith the forearms
ground); front plank andwithtoes brace
in contact with
(as the the ground);
previous exercisefront
but
plank with brace (as the previous exercise but with a bracing maneuver,
with a bracing maneuver, voluntarily contracting the abdominal muscles); supine plank (knees voluntarily contracting the
abdominal muscles); supine plank (knees ◦ , both feet resting on the mat and the pelvis
flexed at 90°, both feet resting on the matflexed
and the at 90
pelvis lifted and aligned with the thigh), lateral
lifted
knee and plankaligned
(in a with the thigh),
side-lying lateral
position withknee
theplank (in a side-lying
dominant side beneath position with the
and knees dominant
support, withsidethe
beneath and knees support, with the elbow beneath the shoulder, the
elbow beneath the shoulder, the other arm perpendicular to the ground, and the pelvis raised); other arm perpendicular to the
ground, and the
lateral plank (aspelvis raised);exercise
the previous lateral plank (as the knees
but without previous exercise but without knees support).
support).

Figure1.1.Exercises
Figure Exercisesperformed:
performed:(1)1)Torso-twist,
Torso-twist,(2)2)Squat,
Squat,(3)
3)Bird-dog,
Bird-dog,(4)
4) Modified
Modifiedcurl-up,
curl-up,(5)
5) Front
Front
plank/front plank with brace, 6) Supine plank, 7) Lateral knee plank and 8) Lateral plank.
plank/front plank with brace, (6) Supine plank, (7) Lateral knee plank and (8) Lateral plank.

Exercise
Exercise intensity
intensity during
during the
the two
two dynamic
dynamic exercises
exercises (i.e.,
(i.e., torso-twist
torso-twist and
and squat)
squat) was
was 15 15
repetition-maximum
repetition-maximum(RM), (RM),which
whichwas
wascalculated
calculatedduring
duringthe
thelast
lastfamiliarization
familiarizationsession.
session.In Inorder
orderto to
do
doso,
so,the
theelastic
elasticbands
bandswere
werepre-stretched
pre-stretchedtotoapprox.
approx. 50%
50% of
of the
theinitial
initial length
length (initial
(initial length,
length, 1.9
1.9 m)
m)
and
andthen
thendifferent bands
different were
bands added
were whenwhen
added needed to reach
needed to the desirable
reach intensity.intensity.
the desirable With thisWith
purpose,
this
red, blue, black, silver and gold elastic band colors were allowed (TheraBand CLX, The Hygenic
Corporation, Akron, OH, USA), alone or in combination. During the performance of the dynamic
exercises, they were asked to use minimal lower body and trunk movement and to perform the
exercises without sudden jerks or accelerations for 3 consecutive repetitions. A metronome was used
to standardize movement velocity at 1.5-s rate for concentric and 1.5-s rate for eccentric. In regard of
the isometric exercises, patients had 2–3 s to reach the proper exercise position, and then they have to
maintain it during 5 s, where EMG signal was recorded. Verbal feedback was provided to start or end
the exercise and to maintain the proper position. A trial was discarded and repeated if participants
were unable to perform the exercise properly.
After each condition, participants were asked to rate tolerability of each individual exercise,
according to the following 5-point scale: very tolerated, tolerated, neutral, little tolerated, not tolerated.
A priori power analysis conducted in G*Power (3.1.9.2 version) software
(Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany) showed that 13 subjects in
Int. J. Environ. Res. Public Health 2019, 16, 3509 5 of 11

this design were sufficient to obtain a statistical power of 0.80 at a medium effect size (f = 0.30), with an
alpha = 0.05.

2.3. Data Analysis

EMG data processing was performed using custom-made algorithms implemented in MATLAB
(The MathWorks, Inc., Natick, Massachusetts, USA, version R2015a) software. During later analysis,
all raw EMG signals obtained during the exercises were digitally filtered, consisting of (1) high-pass
filtering at 10 Hz and (2) a moving root-mean square (RMS) filter of 500 ms. The RMS routine was
performed using a 500-ms smoothing filter/window across the entire signal (i.e., across all contractions).
The RMS filter was centered by performing a root mean-square routine 250 ms backwards and 250 ms
forward from each data point. During the dynamic exercises, for each individual muscle, peak RMS
EMG of each of the three repetitions performed was determined, and the average value of these three
repetitions was then normalized to the maximal RMS EMG obtained during the experimental session
(maximum maximorum EMG of each muscle) [22]. For the isometric exercises, for each individual
muscle, the three highest peaks RMS EMG were averaged in each exercise and then normalized to the
maximal RMS EMG obtained during the experimental session (maximum maximorum EMG of each
muscle).

2.4. Statistical Analyses

Analyses were performed in MATLAB. The normal distribution of peak RMS normalized EMG
was tested using Shapiro-Wilks. The Friedman analysis was applied to assess normalized EMG (nEMG)
differences in each muscle during exercises, as well as to assess tolerability differences. Post hoc
with Bonferroni correction for multiple comparisons was applied when there were multiple random
comparisons. Statistical significance was set to p < 0.05. nEMG data from the current study were
expressed as the median and interquartile range 1 and 3.

3. Results
The demographic characteristics of the participants of the current study are the following: age, 52
(7 SD) years; height, 163.8 (7.8 SD) cm; body mass, 77.8 (24.4 SD) kg and low back pain intensity, 4.3
(2.9 SD). All the subjects considered their job as “standing or walking work that is not strenuous”.
Complete nEMG data induced by the different exercises are presented in Figure 2. The front
plank with brace, front plank and modified curl-up caused the greatest number of between-exercise
statistical differences for the rectus abdominis, without difference between these, and a median nEMG
of 48% (34–61%), 46% (26–61%) and 50% (28–65%), respectively. The front plank with brace induced
the greatest number of between-exercise statistical differences for the external oblique, with a nEMG of
77% (60–97%). The squat and bird-dog exercises provided the greatest number of between-exercise
statistical differences for the erector spinae, with nEMG of 40% (24–87%) and 29% (27–46%), respectively.
P-values of post-hoc comparison between muscle activity of each exercise in the individual muscles
are reported in Table 1.
 with a nEMG of 77% (60–97%). The squat and bird-dog exercises provided the greatest number of
between-exercise statistical differences for the erector spinae, with nEMG of 40% (24–87%) and 29%
(27–46%), respectively. P-values of post-hoc comparison between muscle activity of each exercise in
the individual muscles are reported in Table 1.
Int. J. Environ. Res. Public Health 2019, 16, 3509 6 of 11

Figure 2. EMG during 8 of the 9 exercises (i.e., the lateral plank was not included due to its general
Figure 2. EMG during 8 of the 9 exercises (i.e., the lateral plank was not included due to its general
non-tolerability). Circles show individual data. Numbers between parentheses denote statistical
non-tolerability). Circles show individual data. Numbers between parentheses denote statistical
differences between the exercises (e.g., number 1 means different from the exercise number 1, which is
differences between the exercises (e.g., number 1 means different from the exercise number 1, which
the torso-twist).
is the torso-twist).
Table 1. p-Values of post-hoc comparison between muscle activity of each exercise in the
Table 1. P-values
individual of post-hoc comparison between muscle activity of each exercise in the individual muscles.
muscles.

Exercise
Exercise Exercise
Exercise RECTUS
RECTUS ABDOMINIS
ABDOMINIS EXTERNALOBLIQUE
EXTERNAL OBLIQUE ERECTOR
ERECTOR SPINAE
SPINAE
11 22 1.000
1.000 1.000
1.000 1.000
1.000
11 33 1.000
1.000 1.000
1.000 1.000
1.000
11 44 0.004
0.004 1.000
1.000 0.066
0.066
11 55 0.001
0.001 0.111
0.111 1.000
1.000
1 6 0.014 0.567 0.699
1
1 67 0.014
1.000
0.567
0.291
0.699
1.000
11 78 1.000
0.696 0.291
0.457 1.000
1.000
21 83 0.696
1.000 0.457
1.000 1.000
1.000
22 34 0.180
1.000 1.000
1.000 0.000
1.000
22 45 0.074
0.180 0.029
1.000 0.009
0.000
2 6 0.454 0.182 0.003
2
2 57 0.074
1.000
0.029
0.858
0.009
1.000
22 68 0.454
1.000 0.182
0.142 0.003
1.000
32 74 1.000
0.001 0.858
1.000 <0.001
1.000
32 85 <0.001
1.000 0.111
0.142 0.029
1.000
3
3 46 0.002
0.001 0.567
1.000 0.012
< 0.001
3 7 1.000 0.291 1.000
33 58 <0.180
0.001 0.111
0.457 0.029
1.000
43 65 0.002
1.000 0.567
0.022 0.012
1.000
43 76 1.000
1.000 0.291
0.142 1.000
1.000
43 87 0.002
0.180 1.000
0.457 0.029
1.000
4
4 58 1.000
1.000 0.111
0.022 0.006
1.000
5 6 1.000 1.000 1.000
54 67 1.000
0.001 0.142
<0.001 1.000
0.699
54 78 0.002
1.000 1.000
1.000 0.029
0.231
64 87 1.000
0.009 <0.001
0.111 0.006
0.366
65 68 1.000
1.000 1.000
1.000 0.111
1.000
7 8 0.506 <0.001 1.000
Exercises number: (1) Torso-twist, (2) Squat, (3) Bird-dog, (4) Modified curl-up, (5) Front plank with brace, (6) Front
plank, (7) Supine plank, (8) Lateral knee plank. Bold numbers indicate a statistical difference (p < 0.05).

All exercises were very tolerated except the lateral plank that was not tolerated in general and
the front plank with brace that was generally only tolerated. Tolerability of each exercise is shown in
Figure 3. P-values of post-hoc comparison between tolerability of each exercise are shown in Table 2.
 All exercises were very tolerated except the lateral plank that was not tolerated in general and
the front plank with brace that was generally only tolerated. Tolerability of each exercise is shown
in Figure 3. P-values of post-hoc comparison between tolerability of each exercise are shown in
Table 2.
Int. J. Environ. Res. Public Health 2019, 16, 3509 7 of 11

Figure 3. The tolerability of each exercise.

Figure 3. The tolerability of each exercise
Table 2. p-values of post-hoc comparison between tolerability of each exercise performed.
Table 2. p-values of post-hoc comparison between tolerability of each exercise performed.
Exercise Exercise p-Value
Exercise
1
Exercise 2
p-value 1
1 1 2 3 1 1
1 1 3 4 1 1
1 1 4 5 1 1
1 1 5 6 1 1
1 1 6 7 1 1
1 8 1
1 7 1
1 9 0.002
1 2 8 3 1 1
1 2 9 4 0.002 1
2 2 3 5 1 1
2 2 4 6 1 1
2 2 5 7 1 1
2 2 6 8 1 1
2 9 <0.001
2 7 1
3 4 1
2 3 8 5 1 1
2 3 9 6 < 0.001 0.360
3 3 4 7 1 1
3 3 5 8 1 1
3 3 6 9 0.360 0.472
3 4 7 5 1 1
4 6 1
4 7 1
4 8 1
4 9 0.001
5 6 1
5 7 1
5 8 1
5 9 0.012
6 7 1
6 8 1
6 9 <0.001
7 8 1
7 9 0.001
8 9 0.009
Exercises number: (1) Torso-twist, (2) Squat, (3) Bird-dog, (4) Modified curl-up, (5) Front plank with brace, (6) Front
plank, (7) Supine plank, (8) Lateral knee plank. Bold numbers indicate a statistical difference (p < 0.05).

4. Discussion
The main findings of the study are (1) with the exception of the lateral plank, 8 out of 9 exercises
were well tolerated, and (2) the effectiveness of both front plank exercises (with and without brace)
Int. J. Environ. Res. Public Health 2019, 16, 3509 8 of 11

and the modified curl-up for activating the rectus abdominis, the effectiveness of the front plank with
brace for activating the external oblique and the effectiveness of the squat and bird-dog exercises for
activing the lumbar erector spinae.
Most of the previous studies evaluating a battery of core stability exercises with the aim of
providing evidence-based clinical guidelines were based on EMG in healthy people [12,23]. Recent
examples are two studies [12,24]. evaluating a variety of plank variations performed with and without
suspension in healthy university students. These previous works in healthy people also found that
the front plank was effective in providing activity for the rectus abdominis and the external oblique.
In accordance, we found that this exercise (with and without brace) in NSCLBP patients provides
greater EMG values for the external oblique than for the rectus abdominis. It is worth mentioning
that the brace maneuver did not result in additional rectus abdominis activity during the front plank,
which supports previous findings in NSCLBP patients performing isometric push-ups with/without
brace [25]. Together with both front planks, the modified curl-up was the other exercise achieving the
greatest number of rectus abdominis activity differences between exercises. In agreement with our
findings, other studies reported that the modified curl-up mainly activates the rectus abdominis while
provides less external oblique activity [26].
An interesting finding in our study was the moderate external oblique activity yielded by the
torso-twist exercise, which was considered a promising option for patients with LBP based on data
with healthy sample [27]. Our EMG results show that this exercise is not superior than any other
exercise. In this sense, the greatest number of between-exercises differences in external oblique activity
was provided by the front plank with brace. This contrast is a good example of the importance of
performing such exercise evaluation studies in the specific patient-group of interest, instead of solely
relying on results from healthy subjects. In healthy participants, the lateral plank exercise has been
considered ideal to activate the quadratus lumborum and the abdominal muscles while generates
minimum spinal loading [28]. However, it is worth to mention that in our study, only 3 patients were
able to perform the regular lateral plank (i.e., without knee support) and thus we did not add EMG data
from this exercise. This general absence of tolerability reported by patients with NSCLBP has relevant
practical applications, suggesting that the regular version should be considered an advanced exercise
and only should be used when patients have proper physical conditioning and adequate technique.
Partly, supporting the hypothesis of the present study, it was found that the squat, together with
the bird-dog, were especially effective in activing the lumbar erector spinae. However, these exercises
only induced greater activity than the modified curl-up and both front planks. Partly in accordance,
other studies in NSCLBP patients [15,29] found that the isometric squat performed without external
loads and the lateral plank provided the highest activity of the erector spinae and moderate activity
of the rectus abdominis and external oblique. The fact that external loads can be added during the
squat make this exercise interesting and easy to adapt to different patients, whereas manipulation
to increase relative intensity for each patient during isometric planks is more limited. In addition,
the squat exercise can provide additional lower-limb and functional benefits, since replicates one of the
most typical daily activities. This can be especially relevant for those NSCLBP in more advanced age,
were moving from a sitting position to a standing position is crucial for maintaining independence [30].
Our results suggest that greater erector spinae activity may have been achieved by using higher
intensities, although we do not know whether this would have resulted in tolerability problems.
Interestingly, other exercises designed to challenge low back muscles as the supine plank have shown
relatively low EMG values in healthy participants (even when the exercise was performed with
suspension training) [24] or in NSCLBP patients with the exercise performed under instability with
knees fully extended [31].
A novel aspect of the study was to measure exercise tolerability, which should be used together
with the EMG results for a more proper decision-making (e.g., reducing risk of increasing pain) and
to improve exercise adherence. As could be expected, the highest rates of tolerability were achieved
during the supine plank, which could be considered an easy-to-perform exercise, as also corroborated
Int. J. Environ. Res. Public Health 2019, 16, 3509 9 of 11

by the EMG data provided. Besides the lateral plank, which was mostly non-tolerated, other exercises
that should be more carefully prescribed and supervised in NSCLBP patients are the lateral knee plank
and the modified curl-up, probably due to a difficulty in some patients to maintain the exercise position
and a possible transitory pain exacerbation at the shoulder or the neck respectively. However, all the
exercises with the exception of the lateral plank were generally very tolerated and could be performed
without problems after familiarization. The general non-tolerability showed by the lateral plank has
relevant clinical implications and suggest that before using this exercise, patients should start with the
knee-supported version in order to progressively improve physical conditioning without excessive
physical stress.
The main limitation of the current study could be the small sample size. However, an a priori power
analysis showed that our selected sample size was sufficient. Future studies should corroborate these
findings with a larger sample size, measuring deep muscles if possible and evaluating the association
between nEMG and pain or other biopsychosocial measures (e.g., kinesiophobia). In addition,
well-designed randomized controlled trials are needed to evaluate the efficacy of these exercises on
physical function, pain and quality of life in NSCLBP patients.

5. Conclusions
With exception of the lateral plank, 8 out of the 9 exercises can be implemented in NSCLBP
participants to progress in muscle activity. Specialists must take into account the non-tolerability
provided by the lateral plank and should consider the knee variation as the first option of this exercise
until proper physical conditioning and exercise technique will be achieved.
The front plank with brace, front plank and modified curl-up can be considered the most effective
exercises in activating the rectus abdominis. The front plank with brace can be considered the most
effective exercise in activating the external oblique, whereas the squat and bird-dog exercises are
especially effective in activing the lumbar erector spinae. Specialists can choose from a variety of
dynamic and isometric exercises, where muscle activity values and tolerability can be used as guide to
design evidence-based exercise programs for outpatients with NSCLBP.

Author Contributions: Conceptualization, J.C. (Joaquín Calatayud), A.E.-E. and J.C. (José Casaña); Data
curation, J.C. (Joaquín Calatayud), A.E.-E., C.C.-M., L.L.A., S.P.-A. and R.A.; Formal analysis, J.C. (Joaquín
Calatayud) and L.L.A.; Investigation, J.C. (Joaquín Calatayud) and A.E.-E.; Methodology, J.C. (Joaquín Calatayud);
Writing—original draft, J.C. (Joaquín Calatayud), A.E.-E. and L.L.A.; Writing—review & editing, C.C.-M., S.P.-A.,
R.A. and J.C. (José Casaña).
Funding: This research received no external funding.
Acknowledgments: The authors thank Ricardo Roldán and Maite Morell for their great help in recruiting patients.
Conflicts of Interest: The authors declare no conflict of interest.

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