EVALUATION OF FUNCTIONAL AND NEUROMUSCULAR

CHANGES AFTER EXERCISE REHABILITATION FOR LOW

BACK PAIN USING A SWISS BALL: A PILOT STUDY
Paul W.M. Marshall, PG Dip Sci,a and Bernadette A. Murphy, PhDb

ABSTRACT
Objective: The purpose of this pilot study was to use a multidimensional model to evaluate deficits in patients with low
back pain (LBP) over the course of a 12-week rehabilitation program using the Swiss ball.
Methods: A within-subjects, repeated-measures design based at the University exercise training clinic was used. Twenty
patients with chronic nonspecific LBP (12 men, 8 women; symptom duration, 4.8 years; 38.8 F 12.1 years old; height,
1.76 F 0.06 m; weight, 76.15 F 7.21 kg) participated in this study. Self-report measures were the Oswestry Disability
Index, Visual Analog Scale, Medical Outcomes 12-Item Short Form Health Survey, and Self-Efficacy For Exercise Scale.
Physiologic measures were electromyography measurement of feedforward muscle activation, flexion relaxation
phenomenon, myoelectric fatigue, endurance capacity measured by the Sorenson test, and a modified sit-up test.
Individuals performed 12 weeks of progressive exercise periodized every 4 weeks using a Swiss ball. Outcome measures
were assessed at baseline, 4 weeks, 8 weeks, 12 weeks, and at a 3-month follow-up. Repeated-measures analysis for
variance for time differences and regression analysis for variance in Oswestry scores were performed.
Results: The Oswestry score for self-reported disability significantly decreased over the intervention (F4,14 = 19.456,
P b .001). Significant improvements in pain and disability maintained to the 3 months of follow-up. There were significant
changes in perceptions of physical and mental well-being, erector spinae fatigue, and flexion relaxation measures. Change
in flexion relaxation explained 38% of the improvement in Oswestry scores at the 12-week measurement.
Conclusions: This study showed that the Swiss ball may be successfully used in a rehabilitation context for patients
with LBP. This pilot study has used a novel approach to assess improvements during a rehabilitation program, which may
be used in the future to explain differences between different treatment modalities. (J Manipulative Physiol Ther 2006;
29:550-560)
Key Indexing Terms: Low Back Pain; Exercise Therapy; Rehabilitation; Electromyography

lthough the performance of structured exercise can

improve the pain levels and functional capacity of
individuals with nonspecific low back pain
(LBP),1-4 there is no clear consensus on the most effective
exercise protocol for this group.5 Protocols that have been
used in this context include flexion-extension movement
modalities, general aerobic conditioning, strength conditiona

Clinical Supervisor, Exercise Rehabilitation Clinic, Department of Sport and Exercise Science, University of Auckland,
Auckland, New Zealand.
b
Academic Director, Exercise Rehabilitation Clinic, Department
of Sport and Exercise Science, University of Auckland, Auckland,
New Zealand.
Submit requests for reprints to: Paul W.M. Marshall, PG Dip Sci,
Department of Sport and Exercise Science, University of Auckland, Tamaki Campus, Private Bag 92019, Auckland, New Zealand
(e-mail: p.marshall@auckland.ac.nz).
Paper submitted September 17, 2005; in revised form February
15, 2006; accepted April 25, 2006.
0161-4754/$32.00
Copyright D 2006 by National University of Health Sciences.
doi:10.1016/j.jmpt.2006.06.025

550

ing, stretching, core stability exercise, and basic isometric

conditioning.1-3,6-14
To determine which interventions are most effective, a
relevant set of outcome domains needs to be used, which
will afford the identification of possible explanations for
differences in treatment protocol efficacy. In addition, a
valid assessment model will explain why a subgroup of
patients with LBP may improve with one protocol but not
with another. Bombardier15 identified a core set of patientbased outcome measures comprising 5 domains: backspecific function, generic health status, pain, work disability,
and patient satisfaction. A recent review of the evidence for
exercise and LBP used the Bombardier model to assess the
suitability of outcome assessments for different LBP
rehabilitation programs.16 We note that a relevant domain,
which is lacking from the Bombardier model, relates to
neuromuscular deficits found in LBP individuals.
Motor control deficits in the trunk musculature of
individuals with LBP have been reported, yet very little
research exists on the effect of exercise on deficits in
neuromuscular function. In their seminal article, Hodges and

Journal of Manipulative and Physiological Therapeutics

Volume 29, Number 7

Richardson17 found that individuals with LBP exhibited

delayed activation of the transversus abdominis muscle
before rapid upper limb movements when compared with
healthy controls. It has also been shown that individuals
with LBP have an impaired ability to consciously contract
transversus abdominis and that this is improved with
specific abdominal stabilization training.7,18 However, there
is currently no evidence regarding whether delayed abdominal activation before rapid limb movements can be modified
by an exercise rehabilitation program.
Deficits in the flexion-relaxation (FR) phenomenon are
another reported problem of LBP. The FR phenomenon is the
electrical silence of the erector spinae muscles that is
observed during full forward-trunk flexion19; it has been
shown that this relaxation is absent in individuals with LBP.
A recent article was the first to show that absence of the FR
phenomenon in LBP individuals can be influenced by an
exercise protocol.20
One way of potentially altering neuromuscular recruitment patterns is to perform exercises on an unstable
surface.21-23 The Swiss ball is a device commonly used in
the recreational training environment, yet its application in a
rehabilitation setting has received little empirical attention.
Research has found that use of the Swiss ball increased the
activity of the rectus abdominis in comparison with muscle
activity on a stable surface.24 Anderson et al25 have
conducted a series of investigations that show changes in
muscle activity and force output during exercises performed
on a Swiss ball. No significant difference in electromyographic (EMG) activity of the pectorals, triceps, latissimus
dorsi, and rectus abdominis was found when performing
maximal isometric chest presses under stable and unstable
conditions. Maximum isometric force was decreased by 60%
with the unstable base.25 Leg extensor and plantarflexor
activity was decreased with exercises performed in the
unstable environment, whereas unstable force production
was also less than on the stable surface.26 In contrast to these
results, upper lumbar, lumbosacral erector spinae, abdominal,
and soleus activity was increased when performing squats
under unstable conditions with the same submaximal load.27
The purpose of this pilot study was to use a multidimensional model to evaluate deficits in patients with LBP over
the course of a 12-week rehabilitation program using the
Swiss ball. Three outcome profiles were used, 2 based on
the recommendations of Bombardier15 and a third based on
neuromuscular deficits known to be associated with LBP.
The physical profile measured basic anthropometric and
endurance characteristics of the abdominal and lumbar
muscles; the psychological profile incorporated assessment
of pain and general well-being, and the neuromuscular
profile measured the activation of the deep abdominals
during rapid limb movement and the FR phenomenon.
This study has 2 novel aspects. First, it will provide
information regarding the effects of Swiss ball training on
individuals with LBP. We are not aware of any other studies

Marshall and Murphy

Swiss Ball Rehabilitation Training

that have evaluated the application of the Swiss ball in a

rehabilitation protocol. Second, by virtue of the multidimensional outcome measures used, including the inclusion of a
neuromuscular domain, it will enable determination of which
specific domains and processes make significant contributions
to any demonstrated improvement(s) in the study participants.

METHODS
Subjects
Twenty patients were recruited from general medical
practitioners, gym goers, chiropractors, and physiotherapists
by personal contacts and referrals as well as television and
newspaper advertising. The inclusion criteria were men and
women 18 to 65 years of age who had experienced back
pain for at least 12 weeks and had not received specific
abdominal stabilization training or spinal manipulation nor
performed an organized regimen of Swiss ball training
within the last 3 months. Exclusion criteria were severe
postural or skeletal abnormalities, obvious neuromuscular
disorder, or spinal damage, as identified by magnetic
resonance imaging, plain film radiographs, or any Accident
Compensation Corporation red flags.28 There were 12 men
and 8 women with a symptom duration of 4.8 years. The
mean age of subjects was 38.8 F 12.1 years, mean height
was 1.76 F 0.06 m, and the mean weight was 76.15 F
7.21 kg. All patients gave informed written consent. The
human subjects ethics review board of the University of
Auckland, New Zealand, approved this study.

Assessment Procedures
Assessments for the patients were carried out by an
independent examiner. The assessments were carried out at
0, 4, and 12 weeks during the intervention and at a 3-month
follow-up session.

Training Intervention
Exercises were taught to the patients by an experienced
exercise scientist, with a postgraduate qualification in
exercise rehabilitation. Exercises were performed 3 times
per week for a total of 12 weeks. The exercise program
was periodized every 4 weeks to progressively increase the
training stimulus (Fig 1). Swiss ball exercises involved in
the training program have been previously investigated to
determine that muscle activity is different from performing
the same exercise on a stable surface.24 The exercise
progression was based on the classic linear model where
the initial period involved low-intensity exercises performed with higher repetitions.29 For the first 4 weeks, the
prescription (based on minimum and maximum targeted
levels of exercise) was 2 to 3 sets of 8 to 10 repetitions
for each exercise. For the rest of the training intervention,
the targeted training range was for 2 to 3 sets of 6 to

551

552

Marshall and Murphy

Swiss Ball Rehabilitation Training

Journal of Manipulative and Physiological Therapeutics

September 2006

Fig 1. Exercises used in the 12-week intervention. The exercises were progressed based on measured EMG activity of the abdominal and
back muscles, with lower relative intensity exercises in the first 4 weeks and higher relative intensity exercises in the last 4 weeks.
8 repetitions for each exercise. The program progressed to
exercises of greater intensity performed with lower
repetitions. From the 4-week point, both groups performed
the same exercises using the Swiss ball. No resistance

training using weights was allowed during the course of

the training intervention. The range of sets and repetitions
was based on the ability to individualize the workload for
each patient based on their physical capacity. This was

Journal of Manipulative and Physiological Therapeutics

Volume 29, Number 7

Marshall and Murphy

Swiss Ball Rehabilitation Training

Fig 2. Electromyographic data demonstrating the flexion relaxation phenomenon. Each of the movement phases are separated into the
3-second segments. Note the significantly greater activity during the reextension phase compared with the flexion phase.
adjusted at each weekly session by the trainer who supervised the program. Trainers involved in this study had at
least an undergraduate degree in the sport and exercise
science discipline.
Partial supervision of the exercise program was carried
out over the course of the 12-week training intervention.
Once per week, each subject was required to meet at the
university training center to perform their required program
under direct supervision of the trainer to ensure that the
correct techniques were being performed. In addition,
training diaries were filled in by the patients. Total workload, based on the number of repetitions performed, was
filled in for each set performed for each exercise for each
exercise session performed by the patient. This workload, as
well as total physical activity (hours spent walking, cycling,
playing sport, or participating in other physical leisure
activities) was collected at each 4-week assessment point
throughout the training intervention.

Outcome Measures
Functional capacity. Functional capacity was assessed using
the Oswestry Disability Index (version 2). This is a 10-item
evaluation of a patients impairment relating to their back
pain and presents a score out of 50, which is converted to a
percentage.30,31
Psychological profile. Pain was evaluated using the Visual
Analog Scale (VAS). The VAS was based on evaluating
the patients pain experienced within the last week with
a 10-cm line anchored to the left (with no pain) and to the
right (with worst pain). Self report of physical and mental
well-being was assessed with the Medical Outcomes

12-Item Short Form Health Survey (SF-12).32,33 The

Self-Efficacy For Exercise Scale was also used. This
assessment was to assess the patients beliefs in their
ability to exercise 3 times per week, fulfilling the requirements of the program shown to them for 40+ minutes per
session over the next 4 weeks.34,35
Neuromuscular profile. Surface electromyography was used to
evaluate fatigue of the back muscles, the FR phenomenon,
and feedforward abdominal activation before rapid limb
movements. Pairs of Ag/AgCl surface electrodes (3M Red
Dot, 2-cm diameter, applied with center-center distance of
3 cm; 3M Health Care, Neuss, Germany) were applied to the
muscles of interest for each measurement. Electromyographic activity was recorded using a GRASS model 15 data
acquisition system (GRASS, West Warwick, RI) and
digitized with a National Instruments analog to digital card
(Austin, Tex) (common mode rejection ratio of 90 dB at
` , 16-bit A/D con60 Hz, input impedance of 100 MU
version), sampled at 2000 Hz into a Pentium III computer
system (Intel Corporation). The raw signal was band-pass
filtered between 10 and 1000 Hz.
Flexion-relaxation procedures. Pairs of surface electrodes were
applied to the right erector spinae (located at the level of
L4-L5), gluteus medius (electrodes located inferior to the
iliac crest, oriented obliquely along the palpated muscle),
and biceps femoris (electrodes positioned half the distance
from the gluteal fold to the center of the knee joint, oriented
along the longitudinal axis of the palpated muscle).
The patients stood with their arms by their side and their
feet shoulder width apart. The position of the feet was marked
for consistency between trials. The subject was required to
bend forward in 3 seconds with their hands by their sides until

553

554

Marshall and Murphy

Swiss Ball Rehabilitation Training

Journal of Manipulative and Physiological Therapeutics

September 2006

Fig 4. Change in Oswestry score over the 12-week intervention for

both groups in the study. Based on the repeated-measures ANOVA,
all time points are significantly different from baseline ( P b .05).

Fig 3. Raw EMG data from a representative subject demonstrating

the response of the abdominal muscles to rapid limb movement.
they could bilaterally touch the lateral malleolus of the ankle
joint. The subject was not restrained during this movement.
The subject was then required to hold at the fully flexed
position for 3 seconds. The reextension phase involved the
subject moving back to the normal upright position in a
3-second movement. A counted time signal coordinated with
the recording of the movement phases was used to pace the
movement (Fig 2). Sufficient practice was provided to ensure
that the correct pacing and familiarization with the procedures was achieved. During practice, a marker was applied to
the subject if the lateral malleolus could not be reached by
the subject to indicate where the end of the flexion phase
was. Three trials were performed by each patient with
1 minute of rest between each trial.
The following readings were taken from the EMG
recordings (Fig 2), based on the calculated root mean
square (RMS, 50-millisecond period) of the raw signal36:
A. The RMS of the maximal activity for 1 second during
the forward flexion phase
B. The RMS of the maximal activity for 1 second during
the fully flexed phase
C. The RMS of the maximal activity for 1 second during
the reextension movement.
For the evaluation of FR, the FR ratio (FRR) was used
for this study.37 The FRR was calculated by dividing the
maximal activity measured during either phase A or C by
the activity measured during phase B. The mean of the
3 trials performed was used to determine the FRR for each
muscle for each subject. Previous research into the FR
response has also used multiple trials to establish the most
accurate measurement possible.38,39
Feedforward muscle activation procedures. Pairs of surface
electrodes were applied to the right and left sides of the
abdominal wall in a site that has been defined as

representing the activity of the internal obliques and

transversus abdominis muscles.40 Briefly, the placement of
the lateral electrode for each pair is located 2 cm medial and
2 cm inferior to the anterior superior iliac spines. This site is
not positioned on the inguinal ligament and does not overlap
either the fibers for the rectus abdominis or external oblique
muscles. The respective fibers for the anterior, medial, and
posterior deltoid were also prepared because these are the
prime movers for the shoulder flexion, abduction, and
extension movements performed in this study.
For the shoulder movement tasks, the patient was
required to stand in a position with the feet placed shoulder
width apart. Five repetitions of each shoulder movement
were performed with the arm in the sagittal plane. Each
repetition was performed as fast as possible in response to a
light signal that was preceded by a warning stimulus. A
random period was generated by the computer for the signal
to move between 0.5 to 1 seconds after the warning
stimulus. Previous research found that the limb movement
velocity of patients with LBP was not different from normal
controls.17 The patient was required to bbreath and relaxQ
between each trial. A rest period of 3 to 5 minutes was
provided between each set of shoulder movements. The
latency between the onset of the abdominal muscles and the
deltoid prime mover formed the basis of the analysis for this
task. The mean latency for the right and left abdominal
signals was calculated for the 5 trials performed for each
movement (Fig 3).
The determination of the muscle onset was performed
using an algorithm written in LabVIEW. The EMG signal
for each channel was digitally smoothed using a Butterworth low-pass filter (fourth order, 100 Hz). The integrated
profile technique was used to determine the onset point for
each muscle, as detailed by Allison.41 Briefly, this technique
involves comparison of the amplitude normalized integral of
the signal to a time normalized curve. The maximum
difference between these 2 functions represents muscle
onset. The analysis window was selected from 150 milliseconds before, and 150 milliseconds after, the approximate

Journal of Manipulative and Physiological Therapeutics

Volume 29, Number 7

Marshall and Murphy

Swiss Ball Rehabilitation Training

Table 1. Data presented for the variables representing the psychological profile of the patients during the rehabilitation program
Time
Measure

F value

4 wk

8 wk

12 wk

3 mo

Pain VAS (%)

Physical well-being
(SF-12)
Psychological
well-being
(SF-12)
Self-Efficacy for
Exercise Scale (%)

5.41244
5.2324

47.39 F 23.72
44.15 F 6.86

32.11 F 24.78
47.30 F 9.56

22.61 F 17.53
51.43 F 7.93

23.94 F 19.71
48.25 F 7.46

20 F 15.82
48.78 F 7.29

3.81444

48.45 F 9.22

49.7 F 7.9

51.24 F 6.79

55.77 F 3.77

51.59 F 6.7

1.587

90.64 F 8.79

83.75 F 17.24

89.11 F 7.71

85.69 F 18.88

81.08 F 16.85

4 Pb .05.
44 Pb .01.

Table 2. Flexion-relaxation ratio results calculated for the muscle signals collected in this study
Muscle

F value for comparison between time points

4 wk

8 wk

12 wk

3 mo

Erector spinae
Gluteus medius
Biceps Femoris

5.574
3.61544
1.046

3.26 F 3.43
1.61 F .69
2.41 F 1.94

4.75 F 3.26
2.39 F 1.7
3.26 F 1.82

7.03 F 3.36
2.42 F 1.73
3.17 F 1.74

6.53 F 3.34
2.46 F 1.59
3.32 F 1.75

4.7 F 2.7
2.58 F 1.37
3.13 F 1.62

4 Pb .01.
44 Pb .05.

visual onset of the deltoid signal. A muscle onset before the

150-millisecond window would indicate premeditation of
the movement command.42 No trials were rejected because
of premeditated muscle activity. Feedforward muscle
activation has been defined as muscle activity that is not a
reflex to the limb movement. The criterion for feedforward
muscle activation was established at 50 milliseconds after
the activation of the prime mover for shoulder movements.42,43 It has been shown that patients with LBP exceed
this criteria during rapid shoulder movements.17
Physical profile. Basic anthropometry was collected from
each subject at every assessment session. The height and
weight of each subject was measured for calculation of the
body mass index (kg 2). Hip and waist girths were
collected from each subject for calculation of the hip/waist
ratio. High waist girths are negatively associated with LBP
in both men and women.44
The Sorenson lumbar endurance test was used to
evaluate the isometric endurance (in seconds) of each
subjects lumbar extensor muscles.45 Briefly, the hips and
legs of the patients were stabilized on a cushioned bench
with the trunk allowed to hang freely. The patients were
required to maintain an extended position parallel to the
lower limbs and the ground for as long as possible. Before
commencing the test, the subjects were familiarized with the
test position by supporting themselves with both hands on a
stable surface beneath them then a single hand beneath
them. The subjects were also required to practice the test
position for 2 to 3 seconds so that they were familiar with
the test position before conducting the endurance test.

A partial curl-up was administered to assess abdominal

muscular endurance. This involves the performance of a
controlled curl-up (metronome set to 50 beats per minute) in
a continuous manner to a maximum of 25 in a 1-minute test
period. Details regarding the performance of this test are
provided elsewhere.44
The spectral compression of the EMG signal measured
from the back muscles was also used as an objective
measure of fatigue. The subject was required to maintain a
30-second isometric contraction in the same position as the
Sorenson endurance test. This was broken down into
30 1-second epochs of signal. Fast Fourier transforms
(512-point Hamming window, 50% overlap) were used to
produce an average power periodgram for every second of
the contraction. The median frequency for each periodgram
was calculated as the frequency that divided the area of the
power spectrum in half. The rate of muscle fatigue was then
estimated from the slope of a regression fit line of the
median frequencies calculated over the course of the
30-second contraction.

Statistical Analysis
SPSS version 11.5 (SPSS, Inc, Chicago, Ill) was used for
the data analysis. A repeated-measures analysis of variance
(ANOVA) was used to determine the change in each
variable over the assessment period (0, 4, 12, and 3 months)
throughout this study. Multiple comparisons between the
time points were performed with Bonferonni adjustment. A
multiple linear regression was used to model the variance in

555

556

Marshall and Murphy

Swiss Ball Rehabilitation Training

Journal of Manipulative and Physiological Therapeutics

September 2006

functional capacity (change in Oswestry) by the variables

identified as changing over the time course of the study
from the ANOVA procedure. A separate regression model
was performed for to each time point where significant
changes in the independent variables were found. The
significance of this study was set at P b .05.

RESULTS
Two patients withdrew from this study. One female
patient was involved in a motor vehicle accident and
sustained a significant whiplash injury, and 1 male patient
chose to pursue a different course of treatment that was
outside the parameters of continued involvement in this
study. Both patients withdrew in the 4- to 8-week period of
the study. Therefore, the statistical analysis was conducted
on the remaining 18 subjects who completed the full
12-week training intervention.

Change in Disability
The Oswestry score for self-reported disability significantly decreased over the intervention (F4,14 = 19.456,
P b .001). All time points were identified as significantly
lower scores compared with baseline (Fig 4). From the
8-week time point, there were no further significant
reductions in Oswestry score.

Psychological Profile
As shown in Table 1, there was a significant decrease in
pain intensity over the intervention period (F4,14 = 5.412,
P b .01). By the 8-week point, the pain intensity was
significantly decreased from baseline, and this did not
change for the 12-week and 3-month measurements, which
remained significantly decreased from baseline. There was
no significant change in exercise self-efficacy scores
throughout the intervention period (F4,14 = 1.587, P = .23).
There was a significant increase for the SF-12 self-perception
of physical well-being component score (F4,14 = 5.232,
P b .01). The 8-week score for this was significantly different
from the baseline score only. There was also a significant
increase over time for the SF-12 self-perception of mental
well being component score (F4,14 = 3.814, P = .027). The
score at the 12-week measurement was significantly different
from all other time points.

Neuromuscular Profile
Table 2 shows the significant changes in the FRR
calculated for the erector spinae over the intervention
period (F4,14 = 5.57, P b .01). The ratios calculated for the
erector spinae at the 8- and 12-week points were
significantly different to both the baseline and 3-month
follow-up measurements. There was no significant difference between the baseline and 3-month results for the
erector spinae FRR. The FRR calculated for the gluteus

Fig 5. Latency data from the response of the right TA/IO muscle
signal to rapid shoulder movements. There were no significant
differences over the time course of the study for the latency
response for either the right or left TA/IO for any of the movement
directions. Note that the latency response during shoulder flexion
exceeded the criteria for feedforward activation of 50 milliseconds
after the deltoid prime mover. TA/IO, Transversus abdominis/
internal oblique.
medius muscle showed a significant increase over time
(F4,14 = 3.62, P = .032), with the 3-month follow-up
identified as being significantly different from baseline.
There was no change in the FRR for the biceps femoris
over the course of the intervention (F4,14 = 1.046, P = .49).
There was no difference over time for the latency results
measured for either the right or left transversus abdominis/
internal oblique for any movement direction. The latency
response measured from the patients exceeded the criteria
for feedforward activation of 50 milliseconds after the
deltoid prime mover (Fig 5).

Physical Profile
There was no significant change from baseline for the
hip and waist measurements (hip circumference, 98.11 F
4.28 cm; waist circumference, 81.72 F 8.22 cm) and body
mass index measures (height and weight) (Table 3). There
was no change in the number of sit-ups the patients could
perform over the course of the intervention (F4,14 = 1.734,
P = .199). Neither was there a change in the raw time
recorded for the Sorenson endurance test (F4,14 = .197,
P = .936). There was a significant improvement in the rate
of myoelectric fatigue measured with spectral rate of
compression during an isometric contraction (F4,14 =
6.357, P = .004). The rate of fatigue measured at the
12-week point was significantly different from the baseline
and 3-month follow-up results. A more positive score
reflects a lower rate of fatigue during the contraction.

Regression Models for Changes in Oswestry Disability Index Scores

Two separate regression models were set up to determine
if the variables that changed significantly could account for

Journal of Manipulative and Physiological Therapeutics

Volume 29, Number 7

Marshall and Murphy

Swiss Ball Rehabilitation Training

Table 3. Physical profile results collected during the study

Measure

F value

4 wk

8 wk

12 wk

3 mo

Sit-ups (no.)
Sorensen (s)
MF (Hz sec 1)

1.734
0.197
6.364

24 F 1.5
142.6 F 42.8
.45 F .40

24.8 F 0.4
146.8 F 44.8
.36 F .25

24.9 F 0.2
145.7 F 39
.24 F .20

25
144.8 F 36.1
.14 F .12

24.9 F 0.3
141.7 F 45.8
.42 F .25

MF indicates median frequency calculated from the EMG power spectrum.

4 P b .01.

Table 4. Results of the multiple linear regression analysis for the independent variables that showed a significant change to the 8- and
12-week time points
Variables in model

Adjusted R 2

F value

Significance

Changes to the 8-wk time point

Psychological domain: VAS, SF-12 PCS
Neuromuscular Domain: FRR ES

0.10
0.16

1.99
4.18

.17
.06

Changes to the 12-wk time point

Psychological domain: VAS, SF-12 MCS
Neuromuscular domain: FRR ES
Physical domain: fatigue ES

0.08
0.38
0.06

1.73
11.36
0.0002

.21
.004
.99

The dependent variable in the regression model is the change in Oswestry Disability Index from baseline to each time point.
ES, erector spinae.

the change in Oswestry Disability Index scores (Table 4). At

the 8-week point, no single variable could be identified as
being able to explain the variance in Oswestry scores.
However, by the 12-week point, the neuromuscular domain,
specifically the change in the FRR for the erector spinae,
explained 38% of the changes in Oswestry score for the
same period (Table 4).

DISCUSSION
Changes in Disability
The decrease in the Oswestry Disability Index score
over the first 8 weeks showed that the exercise program
was effective in improving self-reported functional
capacity. These changes were maintained to the 3-month
follow-up assessment. This result showed that the use of
the Swiss ball as the mode of exercise may lead to positive
results in a rehabilitation program. An interesting question
must be raised about the lack of decrease in the Oswestry
score after the 8-week measurement. This suggests that the
program was an insufficient stimulus after this point for
further improvements. The concept of periodization within
an exercise program is to facilitate progressive functional
adaptation of the tissues.29,46 Within this parameter of a
training program, intensity, frequency, type of exercise, and
time spent training are the variables to manipulate.29 After
the 8-week period the only 1 of these variables manipulated
was the intensity of the exercise. This may have been
insufficient to continue to make physical gains throughout
the rest of the program and may potentially explain the lack
of improvement after the 8-week assessment. The results of

this study suggest that for the initial 8 weeks of an exercise

rehabilitation program for LBP patients, exercise using the
Swiss ball is sufficient to facilitate improvements. What is
important to note is that the improvement in the Oswestry
score was maintained to the 3-month follow-up. After the
3-month follow-up, a follow-up of the patients was made
by phone to determine whether any had purchased their
own Swiss ball since the end of the 12 weeks. Only 2 of
the patients reported that they had purchased a Swiss ball
since the cessation of the 12-week intervention.
A further consideration for why there was no improvement after 8 weeks may be that the initial improvements
were simply a regression to the mean disability level for the
subjects in this study. This means that the initial disability
level they reported was higher than it normally is and the
improvement only reflects a more accurate reporting of their
disability level. Another reason for why there was no
improvement after 8 weeks is the lack of an overall whole
body training stimulus. This is especially relevant for the
hamstrings muscle groups, which had no significant functional change as measured by the FR response. The
hamstring muscles are responsible for maintaining the
posterior pelvic tilt and are therefore another important
muscle in the area of lumbopelvic stability. It may be
possible that the lack of a sufficient training focus for
muscles, such as the hamstrings, prevents further improvements in disability after the 8-week point.

Psychological Changes During the Intervention

The decrease in back pain intensity showed a similar trend
to the decrease in the self-reported disability. Scores on the

557

558

Marshall and Murphy

Swiss Ball Rehabilitation Training

VAS significantly improved from baseline to 8 weeks, but

there was no further improvements after 8 weeks to the
3-month follow-up. Self-perception of physical well-being
(SF-12) also improved to the highest score by the 8-week
point. Self-perception of mental well-being (SF-12) was
significantly improved by the 12-week time point of the
study. This may be because the individuals were aware this
was the end of the study and were in a more positive frame of
mind about their accomplishments over the 12-week period.
Although the improvements in pain and well-being perceptions mirrored the improvements in self-reported functional
capacity, the regression model indicated that the changes in
these psychological variables did not explain the improvements made in the Oswestry scores.
There was no significant change over time in the selfefficacy for exercise scores. The scores at baseline were
high and reflect that the volunteers for this study already
had high confidence in their ability to perform exercise.
This is a distinguishing factor to this study, which is similar
for all training studies that recruit volunteers; the participants have volunteered to participate in an exercise study
so they already have a positive attitude toward exercise. It
may be possible that a group of individuals with LBP, who
have low self-efficacy scores, will respond very differently
to the subjects in this study. This means that the results of
this study should not be generalized to all patients with LBP
because individuals with a negative attitude to exercise may
not respond to the intervention the same way.

Physical Changes During the Intervention

The physical parameter that improved was the rate of
fatigability, as measured by median frequency compression.
This was significantly improved by the 12-week point of the
study. Studies have shown that this measure of lumbar
fatigue improves with physical intervention.3,47,48 There
was no change in lumbar endurance, as measured by the
Sorenson endurance test. This may be due to a higher
baseline endurance score reported for the subjects of this
study, in comparison with previous research that reported a
change.3 It may be suggested that the rate of myoelectric
lumbar fatigue should be included in the neuromuscular
profile as the spectral analysis of the EMG signal is a
reflection of the power distribution from the motor units
recruited during the contraction.49,50 However, the changes
in median frequency of the power spectrum are associated
with physical manifestations of fatigue that lead to a
decrease in motor unit conduction velocity.51-53 Although
this physical assessment of fatigue improved over the
12-week intervention, the regression analysis indicates that
this improvement was not associated with improvements in
self-reported functional capacity.
The modified sit-up test was not an effective measure for
physical capacity in this study. There was no significant
change in this measurement during the study, with most

Journal of Manipulative and Physiological Therapeutics

September 2006

subjects reaching the maximum level for this test at

baseline. Isokinetic or isometric dynamometry may be a
more appropriate method to evaluate the endurance capacity
of the abdominal muscles in LBP subjects.
There were also no changes in the anthropometric
measurements made. Sufficient change in these measures
can only be made if an aerobic component was added to the
program as well as nutritional advice. However, it was not a
purpose of this study to combine multiple types of training
intervention but to determine specifically whether the Swiss
ball has any therapeutic potential because this device has
received little scientific testing despite widespread use in the
gym environment.

Neuromuscular Changes During the Intervention

A recent study found that the FR response could change
with a treatment program.20 The current study has found
that increases in the FRR best explained the changes
measured by the Oswestry Disability Index. Specifically,
by the 12-week point, the change in erector spinae FRR
explained 38% of the variance in the change in Oswestry
Disability Index score. The use of the FRR is in contrast to
the previously mentioned study, which only categorized
whether a patient exhibited FR.20 The FRR provides
quantification of this phenomenon for the tracking of
progression over time and for comparison between different
types of treatment. This study found that the improvements
in FRR were progressively made during the intervention
period. The improvements in the erector spinae FRR
reached their maximum by the 8-week point and did not
significantly change by the 12-week point. Upon cessation
of the specific exercise intervention period the FRR
decreased. This is the first study to quantify a worsening
in the FR phenomenon, defined by the decrease in the FRR,
after the treatment period.
Sihvonen et al54 reports that an absence of FR was more
commonly observed in patients with current pain than those
who are pain-free at the time of testing. This indicates that the
absence of FR is related to the level of pain and associated
guarding of the damaged region. The pattern from this study
shows that the improvement trend in FR was similar to the
improvement in pain intensity. Pain intensity was significantly improved by 8 weeks but did not change throughout
the rest of the intervention period up to the 3-month followup. Flexion-relaxation had improved by the 8-week point but
did not improve further by 12 weeks. There was a significant
decrease in the FRR from 12 weeks to 3 months, with the
values at the 3-month follow-up not being significantly
different from baseline. These results suggest that improvements in FR are not dependent on improvements in
perception of pain intensity, as this perception remained
decreased but the FRR worsened to a level similar to baseline.
This is the first study we know of that has evaluated the
changes in the latency responses of the abdominal muscles

Journal of Manipulative and Physiological Therapeutics

Volume 29, Number 7

with an exercise rehabilitation program. No significant

change in the latency response of the abdominal muscles
was found, although it was shown that the patients in this
study had delayed activation of the deep abdominals during
the shoulder flexion task. The inability to show changes in
the latency response of the abdominal muscles may suggest
a lack of sensitivity of the surface electromyography
technique used in this study. Most of the research into the
activation of the deep abdominal and lumbar muscles during
rapid limb movement has used fine-wire EMG techniques.55
Although the surface technique used in this study has been
shown to be valid and reliable for replicating patterns of
altered motor control,40 it may not be sensitive enough to
detect specific changes in the recruitment of the transversus
abdominis muscle that are suggested to occur with
rehabilitation.6 It is also possible that the Swiss ball training
simply does not influence this particular measure in a
chronic LBP group. It has been previously shown that the
activity of rectus abdominis is increased with Swiss ball
exercises,24 which is in contrast to the currently advocated
stabilization treatment for LBP rehabilitation, where rectus
abdominis activity is minimized.6 The optimal training
program for low back rehabilitation, especially for the motor
control deficits associated with stability, has not been clearly
shown. It is interesting that despite the lack of change in the
feedforward measure, the participants improved significantly on several variables such as the Oswestry, pain scale,
erector spinae fatigability, and feedforward activation.
The lack of a control or comparative exercise group
means that no conclusion can be made about whether Swiss
ball exercises are a more effective mode of training than
other alternatives. This was a pilot study to show that the
Swiss ball could be successfully used in a training regimen
and to show that a multidisciplinary assessment protocol can
provide detailed information to explain the changes that
occur with a training intervention in this subgroup of
patients with LBP.

CONCLUSION
This pilot study showed that the use of the Swiss ball as
the mode of exercise rehabilitation may successfully
improve the functional capacity of patients with chronic
nonspecific LBP. Comparison with different training modalities should be performed to determine if there is one mode
of exercise that is more successful than another for the
rehabilitation of patients with LBP. Future studies should
also investigate whether the progressive implementation of
different training modalities with a greater whole body focus
would lead to more positive long-term outcomes. This study
used a unique model of assessment to evaluate what best
explains the improvements in disability and found that the
improvement in the FRR for the erector spinae best
explained the improvements in disability. This provides
fertile ground for future research; the use of neuromuscular

Marshall and Murphy

Swiss Ball Rehabilitation Training

measures can be used in future exercise studies to tease apart

improvements related to the specificity of physical interventions such as exercise, spinal manipulation, and manual
therapy, from the more global improvements in psychological health and well-being that are found in generalized
multidisciplinary programs.

ACKNOWLEDGMENT
The authors thank the University of Auckland, which
provided an early career research award to Dr Murphy that
funded this project.

REFERENCES
1. Simmonds MJ. Exercise and activity for individuals with
nonspecific back pain. In: Myers JN, Herbert WG, Humphrey
R, editors. ACSMs resources for clinical exercise physiology:
musculoskeletal, neuromuscular, neoplastic, immunologic, and
hemotologic conditions. Philadelphia7 Lippincott Williams &
Wilkins; 2002. p. 125-38.
2. Mannion AF, Muntener M, Taimela S, Dvorak J. A randomized
clinical trial of three active therapies for chronic low back pain.
Spine 1999;24:2435-48.
3. Mannion AF, Taimela S, Muntener M, Dvorak J. Active therapy
for chronic low back pain part 1. Effects on back muscle
activation, fatigability, and strength. Spine 2001;26:897-908.
4. van Tulder MW, Koes BW, Bouter LM. Conservative treatment
of acute and chronic nonspecific low back pain: a systematic
review of randomized controlled trials of the most common
literature. Spine 1997;22:2128-56.
5. Faas A. Exercises: which ones are worth trying, for which
patients, and when? Spine 1996;21:2874-8.
6. Richardson C, Jull G, Hodges P, Hides J. Therapeutic exercise
for spinal segmental stabilization in low back pain. Sydney7
Churchill Livingstone; 1999.
7. OSullivan PB, Twomey L, 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.
8. Moffett JK, Torgerson D, Bell-Syer S, et al. Randomized
controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences. BMJ 1999;319:279-83.
9. Leinonen V, Kankaanpaa M, Airaksinen O, Hanninen O. Back
and hip extensor activities during trunk flexion/extension:
effects of low back pain and rehabilitation. Arch Phys Med
Rehabil 2000;81:32-7.
10. Liemohn W. Exercise prescription and the back. New York7
McGraw-Hill; 2001.
11. Chok B, Lee R, Latimer J, Tan SB. Endurance training of the
trunk extensor muscles in people with subacute low back pain.
Phys Ther 1999;79:1032-42.
12. Carpenter DM, Nelson BW. Low back strengthening for the
prevention and treatment of low back pain. Med Sci Sports
Exerc 1999;31:18-24.
13. Petersen T, Kryger P, Ekdahl C, Olsen S, Jacobsen S. The
effect of McKenzie therapy as compared with that of intensive
strengthening training for the treatment of patients with
subacute or chronic low back pain. Spine 2002;27:1702-9.
14. Frost H, Lamb SE, Moffett JK, Fairbank JC, Moser JS.
A fitness program for patients with chronic low back pain:
2-year follow-up of a randomized controlled trial. Pain
1998;75:273-9.

559

560

Marshall and Murphy

Swiss Ball Rehabilitation Training

15. Bombardier C. Outcome assessments in the evaluation of

treatment of spinal disorders. Spine 2000;25:3100-3.
16. Liddle SD, Baxter GD, Gracey JH. Exercise and chronic low
back pain: what works? Pain 2004;107:176-90.
17. Hodges P, Richardson C. Inefficient muscular stabilization of
the lumbar spine associated with low back pain: a motor control
evaluation of transversus abdominus. Spine 1996;21:2640-50.
18. OSullivan PB, Twomey L, Allison GT. Altered abdominal
muscle recruitment in patients with chronic back pain
following a specific exercise intervention. J Orthop Sports
Phys Ther 1998;27:114-24.
19. Floyd WF, Silver PHS. The function of the erector spinae
muscles in certain movements and postures in man. J Physiol
1955;129:184-203.
20. Neblett R, Mayer TG, Gatchel RJ, Keeley J, Proctor T,
Anagnostis C. Quantifying the lumbar flexion-relaxation
phenomenon: theory, normative data, and clinical applications.
Spine 2003;28:1435-46.
21. Gantchev GN, Dimitrova DM. Anticipatory postural adjustments associated with arm movements during balancing on
unstable support surface. Int J Psychophysiol 1996;22:117-22.
22. Franklin DW, Osu R, Burdet E, Kawato M, Milner TE.
Adaptation to stable and unstable dynamics achieved by
combined impedance control and inverse dynamics model.
J Neurophysiol 2003;90:3270-82.
23. Osu R, Burdet E, Franklin DW, Milner TE, Kawato M.
Different mechanisms involved in adaptation to stable and
unstable dynamics. J Neurophysiol 2003;90:3255-69.
24. Marshall PWM, Murphy BA. Core stability exercises on and
off a Swiss ball. Arch Phys Med Rehabil 2005;86:242-9.
25. Anderson KG, Behm DG. Maintenance of EMG activity and
loss of force output with instability. J Strength Cond Res
2004;18:637-40.
26. Behm DG, Anderson K, Curnew RS. Muscle force and
activation under stable and unstable conditions. J Strength
Cond Res 2002;16:416-22.
27. Anderson K, Behm DG. Trunk muscle activity increases with
unstable squat movements. Can J Appl Physiol 2005;30:33-45.
28. New Zealand Advisory Group. New Zealand acute low back
pain guidelines. Wellington7 Accident Compensation Corporation (ACC); 2003.
29. Kraemer WJ, Ratamess NA. Fundamentals of resistance
training: progression and exercise prescription. Med Sci Sports
Exerc 2004;36:674-88.
30. Fairbank JC, Couper J, Davies JB, OBrien JP. The Oswestry
low back pain disability questionnaire. Physiotherapy 1980;
66:271-3.
31. Fairbank JC, Pynsent PB. The oswestry disability index. Spine
2000;25:2940-53.
32. Ware JE, Kosinski M, Keller SD. A 12-item Short-Form
Health Survey: construction of scales and preliminary tests of
reliability and validity. Med Care 1996;34:220-33.
33. Luo X, George ML, Kakouras I, et al. Reliability, validity, and
responsiveness of the Short Form 12-item Survey (SF-12) in
patients with back pain. Spine 2003;28:1739-45.
34. McAuley E. Self-efficacy and the maintenance of exercise
participation in older adults. J Behav Med 1993;16:103-13.
35. Resnick B, Jenkins LS. Testing the reliability and validity of
the Self-Efficacy For Exercise Scale. Nurs Res 2000;49:154-9.
36. Farina D, Merletti R. Comparison of algorithms for estimation
of EMG variables during voluntary isometric contractions.
J Electromyogr Kinesiol 2000;10:337-49.
37. Watson PJ, Booker CK, Main DJ, Chen ACN. Surface
electromyography in the identification of chronic low back

Journal of Manipulative and Physiological Therapeutics

September 2006

38.
39.

40.

41.
42.
43.
44.

45.
46.
47.

48.

49.

50.
51.

52.
53.
54.

55.

pain patients: the development of the flexion relaxation ratio.

Clin Biomech 1997;12:165-71.
Sihvonen T. Flexion relaxation of the hamstring muscles
during lumbar-pelvic rhythm. Arch Phys Med Rehabil
1997;78:486-90.
Shirado O, Ito T, Kaneda K, Strax TE. Flexion-relaxation
phenomenon in the back muscles. A comparative study
between healthy subjects and patients with chronic low back
pain. Am J Phys Med Rehabil 1995;74:139-44.
Marshall P, Murphy B. The validity and reliability of surface
EMG to assess the neuromuscular response of the abdominal
muscles to rapid limb movement. J Electromyogr Kinesiol
2003;13:477-89.
Allison GT. Trunk muscle onset detection technique for EMG
signals with ECG artifact. J Electromyogr Kinesiol 2003;
13:209-16.
Aruin AS, Latash ML. Directional specificity of postural
muscles in feed-forward postural reactions during fast voluntary arm movements. Exp Brain Res 1995;103:323-32.
Hodges PW, Richardson CA. Feedforward contraction of
transversus abdominis is not influenced by the direction of
arm movement. Exp Brain Res 1997;114:362-70.
Albert WJ, Bonneau J, Stevenson JM, Gledhill N. Back fitness
and back health assessment considerations for the Canadian
physical activity, fitness and lifestyle appraisal. Can J Appl
Physiol 2001;26:291-317.
Biering-Sorenson F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine 1984;
9:106-19.
Fry A. The role of resistance exercise intensity of muscle fiber
adaptations. Sports Med 2004;34:663-79.
Kankaanpaa M, Taimela S, Airaksinen O, Hanninen O. The
efficacy of active rehabilitation in chronic low back pain: effect
on pain intensity, self-experienced disability, and lumbar
fatigability. Spine 1999;24:1034-49.
Kankaanpaa M, Taimela S, Airaksinen O. Reference
change limits of the paraspinal spectral EMG in evaluation
of low back pain rehabilitation. Pathophysiology 1998;5:
217-24.
Bigland-Ritchie B, Rice C, Garland SJ, Walsh ML. Task
dependent factors in fatigue of human voluntary contractions.
In: Gandevia SC, Enoka RM, McComas AJ, Stuart DG,
Thomas CK, editors. Fatigue: neural and muscular mechanisms. New York7 Plenum Press; 1995. p. 361-80.
Dimitrova NA, Dimitrov GV. Interpretation of EMG changes
with fatigue: facts, pitfalls and fallacies. J Electromyogr
Kinesiol 2003;13:13-36.
Arendt-Nielsen L, Gantchev N, Sinkjaer T. The influence of
muscle length on muscle fiber conduction velocity and
development of muscle fatigue. Electroencephalogr Clin
Neurophysiol 1992;85:166-72.
Brody L, Pollock ML, Roy S, DeLuca CJ, Celli B. pH induced
effects on medium frequency and conduction velocity of the
myoelectric signal. J Appl Phys 1991;71:1878-85.
Mortimer JT, Magnusson R, Petersen I. Conduction velocity in
ischemic muscle: effect on EMG frequency spectrum. Am J
Physiol 1970;219:1324-9.
Sihvonen T, Partanen J, Hanninen O, Soimakallio S. Electric
behavior of low back muscles during lumbar pelvic rhythm in
low back pain patients and healthy controls. Arch Phys Med
Rehabil 1991;72:1080-7.
Hodges P, Richardson C. Contraction of the abdominal
muscles associated with movement of the lower limb. Phys
Ther 1997;77:132-44.