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This study aims to investigate the interactive effects of two core stability training strategies-abdominal drawing-in manoeuvre (ADIM) and Dynamic Neuromusculoskeletal Stabilization abdominal expansion (DNS-AE)-and two instructional approaches (verbal cueing and manual facilitation) on training outcomes in individuals with chronic non-specific low back pain.
A 2×2 factorial randomized controlled trial design will be employed. Ninety-six participants with chronic non-specific low back pain will be randomly allocated, using block randomization, to one of four intervention groups in equal proportions. All groups will receive a 4-week intervention program, with training conducted twice per week.
Outcome measures will be assessed at four time points: before the intervention (baseline), immediately after the first training session, at the completion of the 4-week intervention, and at a 3-month follow-up, to evaluate short-term and mid-term effects as well as the sustainability of training outcomes.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| ADIM With Verbal Cueing | Experimental | Participants receive abdominal drawing-in manoeuvre training with verbal cueing, delivered twice weekly for 4 weeks. |
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| ADIM With Manual Cueing | Experimental | Participants receive abdominal drawing-in manoeuvre training with manual facilitation, delivered twice weekly for 4 weeks. |
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| DNS-AE With Verbal Cueing | Experimental | Participants receive Dynamic Neuromusculoskeletal Stabilization abdominal expansion training with verbal cueing, delivered twice weekly for 4 weeks. |
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| DNS-AE With Manual Cueing | Experimental | Participants receive Dynamic Neuromusculoskeletal Stabilization abdominal expansion training with manual facilitation, delivered twice weekly for 4 weeks. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Abdominal Drawing-In Manoeuvre Training | Behavioral | Abdominal drawing-in manoeuvre (ADIM) training is a core stability exercise strategy emphasizing selective activation and coordination of the deep abdominal musculature to enhance local trunk stability. Participants receive individualized, one-on-one training delivered by licensed physical therapists, conducted twice weekly for 4 weeks. Training is performed across functional positions and task-specific movements, with instruction provided using either verbal cueing or manual facilitation according to group allocation. |
| Measure | Description | Time Frame |
|---|---|---|
| Pain intensity | Pain intensity assessed using the Visual Analogue Scale (VAS), ranging from 0 to 10, where 0 indicates no pain and 10 indicates the worst pain imaginable, with higher scores indicating greater pain intensity. | At baseline, after the first week of intervention, and at the end of the 4-week intervention. |
| Movement control performance | Movement control performance assessed using the Nine-Item Movement Control Test Battery, which evaluates movement quality during standardized functional movement tasks. Each item is scored according to predefined error-based criteria, and item scores are summed to produce a total score ranging from 0 to 93, with higher scores indicating poorer movement control performance. | At baseline, after the first week of intervention, and at the end of the 4-week intervention. |
| Measure | Description | Time Frame |
|---|---|---|
| Disability related to low back pain | Disability assessed using the Oswestry Disability Index (ODI), with total scores ranging from 0 %to 100%, where higher scores indicate greater disability. | At baseline, at the end of the 4-week intervention, and at 3-month follow-up. |
| Patient-specific functional ability |
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Inclusion Criteria:
Exclusion Criteria:
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| Dynamic Neuromusculoskeletal Stabilization Abdominal Expansion Training | Behavioral | Dynamic Neuromusculoskeletal Stabilization abdominal expansion (DNS-AE) training focuses on coordinated breathing and abdominal expansion to facilitate intra-abdominal pressure regulation and integrated postural control. Participants receive individualized, one-on-one training delivered by licensed physical therapists, conducted twice weekly for 4 weeks. Training is performed across functional positions and task-specific movements, with instruction provided using either verbal cueing or manual facilitation according to group allocation. |
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Functional ability assessed using the Patient-Specific Functional Scale (PSFS), with scores ranging from 0 to 10, where 0 indicates inability to perform the activity and 10 indicates the ability to perform the activity at the pre-injury or normal level, with higher scores indicating better functional ability. |
| At baseline, at the end of the 4-week intervention, and at 3-month follow-up. |
| Perceived movement difficulty assessed using the Perceived Difficulty Index (PDI). | Perceived difficulty during movement performance assessed using the Perceived Difficulty Index (PDI). Participants rate the level of difficulty experienced during the movement tasks on a numeric rating scale ranging from 0 to 10, where 0 indicates no perceived difficulty and 10 indicates extreme difficulty, with higher scores indicating greater perceived difficulty. | At baseline, after the first week of intervention, and at the end of the 4-week intervention. |
| Central sensitization symptoms | Symptoms related to central sensitization assessed using the Central Sensitization Inventory (CSI), with total scores ranging from 0 to 100, where higher scores indicate greater symptom severity related to central sensitization. | At baseline and at the end of the 4-week intervention. |
| Fear-avoidance beliefs | Fear-avoidance beliefs assessed using the Fear-Avoidance Beliefs Questionnaire (FABQ), with total scores ranging from 0 to 96, where higher scores indicate greater fear-avoidance beliefs. | At baseline and at the end of the 4-week intervention. |
| Pain catastrophizing | Pain catastrophizing assessed using the Pain Catastrophizing Scale (PCS), with total scores ranging from 0 to 52, where higher scores indicate greater pain catastrophizing. | At baseline and at the end of the 4-week intervention. |
| Pressure pain threshold | Pressure pain threshold (PPT) assessed using a pressure algometer. | At baseline and at the end of the 4-week intervention. |
| Global perceived change | Overall perceived change assessed using the Global Rating of Change (GROC) scale, ranging from -7 to +7, where negative scores indicate perceived worsening, 0 indicates no change, and positive scores indicate perceived improvement, with higher scores indicating greater perceived improvement. | At the end of the 4-week intervention and at 3-month follow-up. |
| Learning acquisition during training | Learning acquisition assessed by the instructor after each training session using a numeric rating scale from 0 to 10. | After each training session during the 4-week intervention. |