Efficacy of 6 Week Core Training Program for Balance, Core Endurance, and Low Back Pain

This study investigates the efficacy of a 6-week core training program on balance, core endurance, and low back pain. Statistical analysis reveals improvements in balance deficits and reduction in low back pain disability. Core endurance exercises in the lumbopelvic region are recommended for better functional outcomes and low back pain prevention.

Chapter 5. Discussion
This study aims to investigate the efficacy of the 6 week core training program: the
relationship between balance, core endurance and low back pain based on dynamic balance of
lower limb (Y-Balance Test), core stability on unstable surface (Swiss Ball Four Point Kneeling
Test) and static core endurance (Biering-Sorensen Test, Prone Bridge, Right Side Bridge & Left
Side Bridge) in trainee riders from Hong Kong Jockey Club. In order to investigate the given
study and analyze the outcomes of 6-weeks training program IBM SPSS statistical Base 24.0
software has been used by researchers. This statistical test provided more effective and reliable
information that helps in checking viability of result. Here, data has been expressed as mean ±
standard deviation (SD), where main purposes of conducting statistical analysis was two test the
viability on the basis of pre-test and post-test.
5.1.1 Balance - Y-Balance Test (YBT):
There are various studies investigating the correlation between low back pain and
neuromuscular control of the lumbar spine (Soomro and et. al., 2016). However, there has not
been many researches evaluating the effectiveness of neuromuscular training among low back
pain population. In this regard, in order to measure the effectiveness of training proprioceptive
training on agility in Hong Kong national first-team cricket players YBT test has been used by
project team of present study. It is a dynamic balance test which requires neuromuscular
control, previous research indicated that YBT is highly reliable in assessing dynamic balance of
an individual (Plisky et al., 2009). Hooper et al (2016) reported that subject with low back pain
history would have reduced performance in posteromedial reach and posterolateral reach in
YBT.
After 6-weeks core training program with the trainee riders, it has been evaluated
through statistical analysis that the results obtained through YBT Test showed there was only 1

significant difference out of 6 reached directions i.e. Right Posterolateral Reach (YBTRPL),
which means there is a chance that the 6-weeks core training program could have improved the
balance deficits of trainee riders and reduced low back pain disability (Hooper et al., 2016). For
the effect of neuromuscular training, as comparison from previous investigation, which has
proven that neuromuscular training does not show any immediate effect on reducing the low
back pain symptom, the present investigation through YBT test has shown that there is no
significant difference among same. Unsgaard-Tøndel et al (2010) reported that neuromuscular
control should not be neglected because applying balance exercise not only show better
outcome when compared to other exercise therapy in the reduction of low back pain symptom
(Saragiotto et al., 2016) but balance or any other motor control exercise would enhance the
isolated voluntary contractions of the deep muscles such as transversus abdominis and
multifidus muscles which was shown to be associated to low back pain (Unsgaard-Tøndel et al.,
2010). Gatti et al (2010) reported that the combination of balance and flexibility exercise would
reduce the low back pain symptom.
5.1.2 Balance - Swiss Ball Four Point Kneeling Test (SBFPKT):
It has been evaluated through SBFPKT test that however, there is no significant
difference in exercise effect after 12 weeks of core training, but the mean was still increased.
So, as per perception of Kovácsné et al. (2017), it has been analyzed that there is a rapid
improvement in self-rated chronic low back pain disability after Swiss ball exercise (Marshall
& Murphy, 2008).
Patient with low back pain or any dysfunction in lumbar region normally display
reduced performance with Swiss ball (Chung, Lee & Yoon, 2013). According to Sundstrup et al
(2012) Swiss ball exercise could be used to examine the neuromuscular control and core
strength of the individual because insufficient motor and contractile strength of the core

muscles would lead to lumbar spine instability as well as low back pain (Kovácsné et al., 2017).
Chung, Lee and Yoon (2003) also stated that insufficient neuromuscular control would reduce
the adaption of sudden changes of the center of gravity on unstable surface which may result in
low back pain.
According to Escamilla et al (2010), the use of Swiss ball in core exercise will show
high core muscle activation in electromyographic (EMG) when compared to other general core
exercise, because Swiss ball provides perturbation and challenge to the neuromuscular control
of the trunk. Previous researches also reported that performing crunches on Swiss ball may
enhance rectus abdominis activation (Marshall & Desai, 2010); doing bridging exercise with
Swiss ball will also increase core muscle activity (Lehman, Hoda & Oliver, 2005; Saliba et al.,
2010). Therefore, applying Swiss ball into stabilization should result in better neuromuscular
control and may have injury prevention function for individuals with low back pain (Lee,
Hwangbo & Lee, 2014), which could explain the increased mean difference of SBFPKT in pre-
and post-test in the results obtained after the 6 weeks core training program.
5.1.3 Core Endurance - Biering-Sorensen Test (BST)
BST Test is mainly used to examine examining the endurance of back extensor muscles
because various studies reported the endurance of back extensor muscles was considered as one
of the risk factors of low back pain (Luoto et al., 1995). Therefore, it has been evaluated
through the result obtained in BST Test there is a significant difference between pre- and post-
test. But there is no significant difference in eliminating low back pain among patient with
minimal disability and low back pain history after 6 weeks intervention program took place
(Kim and Park, 2016). Steiger et al. (2012) indicated that BST was commonly used in. In
addition, Latimer et al. (1999) investigated the correlation between BST and nonspecific low

back pain and found that high occurrence of low back pain was shown in individual with
decreased position holding time in BST.
The findings in the present study where low back pain did not improve after 6 weeks of
core training program is not surprising (Cheatham, Kolber and Shimamura, 2016). As found in
Harts et al. (2008), a 16 weeks of lumbar strengthening program also did not show significant
difference in decreasing low back pain, but it was reported that pain reduction in self-assessed
of low back pain symptoms.
There has been limited studies indicating that isolated back strengthening program
would lead to reduction of low back pain (Johnson et al., 2009; Durall et al., 2009; Kankaanpää
et al., 1999). However, previous research reported lumbar stabilization exercise would not only
reduce the severity of low back pain but also maximizes the isometric strength of lumbar
extensors therefore reduce low back pain (Moon et al., 2013; Johnson et al., 2009), this explains
why the significant difference in BST in this study because isometric strength of back extensor
muscles may have improved after the 6 weeks core training program.
Although the back-extensor muscles endurance is one of the risk factor for low back
pain, previous researches suggested not to use isolated back extensor endurance training as the
only training to prevent low back pain (Chok et al., 1999; Steele, Bruce-Low & Smith, 2014;
Balagué et al., 2010; Helmhout et al., 2008); Moon et al. (2013) reported the combination of
lumbar stabilization exercises should be used for better functional outcome.
5.1.4 Core Endurance - Prone Bridge, Right Side Bridge, Left Side Bridge
According to Wright and Atkinson (2019), it has been evaluated that the results obtained
through two core endurance test as Prone Bridge (PB) and Left Side Bridge (LSB), shows that
there was significant difference in these two terms. But there is no significant difference was

presented in Right Side Bridge (RSB) but the mean of RSB was increased after the 6 weeks
core training program (Mokhtar, 2018).
Vanti et al (2016) found that there was significant correlation in prone bridge test and
low back pain symptoms which indicated that the disability of nonspecific low back pain is
related to core endurance. Further Sandrey and Mitzel (2013) reported 6-weeks core training
with 3 sessions per week, improved both RSB and LSB performance and indicated the
relationship between both side bridge performance and core endurance.
Abdelraouf and Abdel-aziem (2016) indicated that poor core endurance in trunk
extensor and flexors are associated with low back pain. Previous researches reported improving
core endurance would enhance the stability of the lumbar spine which in turn reduce
nonspecific low back pain (Hodges, 2003); this finding is also supported by the studies in
Smith, Littlewood and May (2014) which further indicated that the combination of core stability
and endurance exercise may reduce low back pain.
Further, Hides et al (2008) showed that a 13 weeks core stabilization program that
focuses on core endurance on isometric contraction of core muscles especially multifidus will
help to reduce low back pain symptom and self-report pain; another study found that core
endurance exercise in lumbopelvic region is effective in reducing the levels of low back pain
related disability (Lee and Kim, 2015); by performing bridging endurance exercise on unstable
surface would increase activation of stabilizers which also result in pain reduction (Saliba et al.,
2010). Rydeard, Leger and Smith (2006) also reported neuromuscular and core endurance
training on lumbar-pelvic region presented a significant difference in the reduction of pain
intensity and functional disability in a 12 months follow-up. Hoppes et al (2016) showed
significant difference in the activation of transversus abdominis in standing after 8 weeks core
stabilization program which lead to reduction in low back pain.

To conclude, core endurance exercise in lumbopelvic region focuses on both trunk
extensor and flexors not only improves functional outcome, but may reduce low back pain, and
the result in this present study showing significant difference in PB indicates that the 6 weeks
core training program not only effectively improved core endurance but can reduce low back
pain in a long run (Pearson, 2016).
Therefore, it has been concluded from this overall discussion that statistical analysis
helps in understanding the effectiveness of training program more appropriately. As compare
with traditional research methodologies like questionnaire and interview techniques, statistical
test measures the viability of result more appropriately. Here, in present research YBT test has
proven that by concerning on importance of neuromuscular and creating a combination of
balance and flexibility exercise would reduce the low back pain symptom. Therefore, training
should be provided in flexible manner to cricket team players which helps in preventing them
from high back pain. Similarly, through another test i.e. SBPFKT it has been analyzed that,
Swiss ball in core exercise lead to high core muscle activation in electro-myographic (EMG) as
compared with other general core exercise. This exercise provides perturbation as well as
challenge to the neuromuscular control of the trunk which helps in reducing the low back pain to
trainees. Along with this, it has been proven through the test of BST, that neither 6 weeks nor 16
weeks training program create a significance difference between pre ad post-test. It states that
there is no improvement in low back pain due to any lumbar strengthening program. Therefore,
concerning on combination of lumbar stabilization exercises should be used for better functional
outcome.

5.2 Limitation
All the participants in this study are currently following horseracing training program
provided by Hong Kong Jockey Club, the details of their program are confidential and not made
known to us which means trainee riders could attend the core training session with unpredicted
physical condition during each session (Ravier and et. al., 2018). Further the training sessions
were scheduled at late afternoon which trainee riders might be mentally and physically fatigue
from their own training program before attending our core training session. Our training
program and follow-up period were short, and since the outcome may not present immediately
after training, researchers were unable to distinguish the positive outcomes are from their own
horseracing training program or our core training program (Hides and et. al., 2016). Last but not
the least, all subjects were male and some of them were not able to attend the core training
session twice a week due to their own HKJC training schedule. All these factors could possibly
affect the result of this study.
5.3 Conclusion
To conclude, the results in this study shows that 6 weeks core training program is
effective to improve core endurance and showed a positive correlation between low back pain
and core training program. The results obtained showed that there are more significant
difference in core endurance (BST, PB & LSB) than in balance. For better functional outcome
and low back pain prevention, it is suggested that core endurance exercise should focus on
lumbopelvic region (Rydeard, Leger and Smith, 2006) and both trunk extensors and flexors
(Abdelraouf and Abdel-aziem, 2016). However, neuromuscular training should not be neglected
even there was only one significant difference (YBTRL) reported in this study, it is because
balance deficit reflects the poor activation of the deep core muscles such as multifidus and these
delayed muscles activation will affect the voluntary muscle contractions which in turn may lead

to low back pain (Unsgaard-Tøndel et al., 2010); and balance exercise together with good
flexibility will also help to reduce low back pain (Gatti et al, 2010).
5.4 Recommendation
In order to increase the effectiveness of training program for cricket team players, it has
been recommended to Honk Cong Club that if trainers concern on providing flexibilities during
exercise, then there will be high result obtained in reducing the low back pain. It is also
recommended to perform core training on Swiss ball to maximize the activation of the core
muscles which may improve core endurance and neuromuscular control at the same time. To
conclude, the results obtained in this study showed that the 6 weeks core training program is
effective in improving core endurance but not balance and it may be useful for preventing low
back pain in trainee riders. Along with this, concerning on giving core endurance exercise
within lumbopelvic region that focuses more on needs of both trunk extensor and flexors, will
not only improve the functional outcome, but also lead to reduce low back pain, in a long run
manner.
5.5 Areas of further research
Since the major limitation of this study is not getting appropriate information due to
confidently where all the players were following horseracing training program that are provided
by Hong Kong Jockey Club. Therefore, researchers of present study need to conduct further
investigation on exploring the details of core training session, including the unpredicted
physical condition during each session. As training time is generally start during noon which
may lead to create more tiredness on physical and mental state of trainees. Therefore,
investigation must go in this direction also to evaluate if timing of trainings decreases the
effectiveness of training program or not. This would aid to provide more efficient
recommendation to Honk Cong Club in improving their training program procedures.

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