Multimodal exercise programs do not specifically target lumbar paraspinal musculature, but incorporate aspects of different exercises to have an overall benefit.
Objective
To investigate the effect of a multimodal exercise program on paraspinal muscle volume and composition, and patient outcomes in individuals with chronic low back pain (CLBP).
Methods
Thirty-four participants with CLBP either completed a 14-week high-intensity training program (n = 8) including cardiorespiratory and resistance exercises 3 sessions per week or were waitlisted (n = 26). Participants underwent magnetic resonance imaging at baseline and post-intervention to assess paraspinal muscle volume (cm3) and fatty infiltration (% FI) at L3-L4, L4-L5, and L5-S1. Pain, disability, quality of life, pain-related fear (catastrophizing and Kinesiophobia), and anxiety were assessed via validated self-reported questionnaires.
Results
Mixed-design ANOVA revealed no significant time × group interactions for paraspinal muscle volume and %FI. An exploratory analysis revealed a significant increase in multifidus %FI in the control group at L3-L4, L4-L5, and L5-S1, with a concomitant increase in multifidus volume at L3-L4 and L5-S1. The exercise group had a significant increase in multifidus %FI and volume at L5-S1. Significant time × group interactions for pain, disability, catastrophizing and kinesiophobia, and a main effect of group in physical and mental health were found. Significant correlations were found between changes in patient-reported and functional outcomes with paraspinal muscle morphology.
Conclusion
Multimodal exercise programs may help prevent LBP-related paraspinal muscle atrophy and %FI, and lead to concomitant improvements in pain, disability and pain-related fear in individuals with CLBP.
The Lancet R. The global epidemic of low back pain. Lancet Rheumatol2023; 5: e305.
2.
ItzCJGeurtsJWvan KleefM, et al.Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in primary care. Eur J Pain2013; 17: 5–15. 2012/05/30.
3.
WuAMarchLZhengX, et al.Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med2020; 8: 299. 2020/05/02.
4.
Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol2023; 5: e316–e329. 2023/06/05.
5.
MeucciRDFassaAGFariaNM. Prevalence of chronic low back pain: systematic review. Rev Saude Publica2015; 49: 1. 2015/10/22.
6.
DionneCEDunnKMCroftPR, et al.A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine2008; 33: 95–103.
7.
FosterNEAnemaJRCherkinD, et al.Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet2018; 391: 2368–2383. 2018/03/27..
8.
DagenaisSCaroJHaldemanS. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J2008; 8: 8–20. 2008/01/01..
9.
RissanenAKalimoHAlarantaH. Effect of intensive training on the isokinetic strength and structure of lumbar muscles in patients with chronic low back pain. Spine (Phila Pa 1976)1995; 20: 333–340. 1995/02/01.
10.
HolmesBLeggettSMooneyV, et al.Comparison of female geriatric lumbar-extension strength: asymptotic versus chronic low back pain patients and their response to active rehabilitation. J Spinal Disord1996; 9: 17–22. 1996/02/01.
11.
RainvilleJAhernDKPhalenL, et al.The association of pain with physical activities in chronic low back pain. Spine (Phila Pa 1976)1992; 17: 1060–1064. 1992/09/01.
12.
MayerTGGatchelRJMayerH, et al.A prospective two-year study of functional restoration in industrial low back injury. An objective assessment procedure. Jama1987; 258: 1763–1767. 1987/10/02.
13.
van der VeldeGMierauD. The effect of exercise on percentile rank aerobic capacity, pain, and self-rated disability in patients with chronic low-back pain: a retrospective chart review. Arch Phys Med Rehabil2000; 81: 1457–1463. 2000/11/18.
14.
ShiriRKarppinenJLeino-ArjasP, et al.The association between obesity and low back pain: a meta-analysis. Am J Epidemiol2010; 171: 135–154. 2009/12/17.
15.
RangerTACicuttiniFMJensenTS, et al.Are the size and composition of the paraspinal muscles associated with low back pain? A systematic review. Spine J2017; 17: 1729–1748. 2017/08/02.
16.
KjaerPBendixTSorensenJS, et al.Are MRI-defined fat infiltrations in the multifidus muscles associated with low back pain?BMC Med2007; 5: 2. 2007/01/27.
17.
CuellarWAWilsonABlizzardCL, et al.The assessment of abdominal and multifidus muscles and their role in physical function in older adults: a systematic review. Physiotherapy2017; 103: 21–39. 2016/09/27.
18.
WesselinkEOPool-GoudzwaardADe LeenerB, et al.Investigating the associations between lumbar paraspinal muscle health and age, BMI, sex, physical activity, and back pain using an automated computer-vision model: A UK Biobank study. Spine J2024. 2024/02/29. DOI: 10.1016/j.spinee.2024.02.013
19.
SnodgrassSJStanwellPWeberKA, et al.Greater muscle volume and muscle fat infiltrate in the deep cervical spine extensor muscles (multifidus with semispinalis cervicis) in individuals with chronic idiopathic neck pain compared to age and sex-matched asymptomatic controls: a cross-sectional study. BMC Musculoskelet Disord2022; 23: 973. 2022/11/12.
20.
D'hoogeRCagnieBCrombezG, et al.Increased intramuscular fatty infiltration without differences in lumbar muscle cross-sectional area during remission of unilateral recurrent low back pain. Man Ther2012; 17: 584–588.
21.
SionsJMElliottJMPohligRT, et al.Trunk muscle characteristics of the multifidi, erector spinae, psoas, and Quadratus lumborum in older adults with and without chronic low back pain. J Orthop Sports Phys Ther2017; 47: 173–179. 2017/02/06.
22.
SionsJMCoylePCVelascoTO, et al.Multifidi muscle characteristics and physical function among older adults with and without chronic low back pain. Arch Phys Med Rehabil2017; 98: 51–57. 2016/09/04.
23.
MaherCG. Effective physical treatment for chronic low back pain. Orthop Clin North Am2004; 35: 57–64. 2004/04/06.
24.
HaydenJAEllisJOgilvieR, et al.Exercise therapy for chronic low back pain. Cochrane Database Syst Rev2021; 9: Cd009790. 2021/09/29.
25.
GordonRBloxhamS. A systematic review of the effects of exercise and physical activity on non-specific chronic low back pain. Healthcare (Basel)2016; 4: 22. 2016/07/16.
26.
RainvilleJHartiganCMartinezE, et al.Exercise as a treatment for chronic low back pain. Spine J2004; 4: 106–115. 2004/01/30.
27.
SteeleJBruce-LowSSmithD. A review of the clinical value of isolated lumbar extension resistance training for chronic low back pain. Pm r2015; 7: 169–187. 2014/12/03.
28.
SearleASpinkMHoA, et al.Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clin Rehabil2015; 29: 1155–1167. 2015/02/15.
29.
van MiddelkoopMRubinsteinSMVerhagenAP, et al.Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol2010; 24: 193–204. 2010/03/17.
30.
OwenPJMillerCTMundellNL, et al.Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. Br J Sports Med2020; 54: 1279–1287. 2019/11/02.
31.
HaydenJAEllisJOgilvieR, et al.Some types of exercise are more effective than others in people with chronic low back pain: a network meta-analysis. J Physiother2021; 67: 252–262. 2021/09/21.
32.
ShahtahmassebiBHebertJJStomskiNJ, et al.The effect of exercise training on lower trunk muscle morphology. Sports Med2014; 44: 1439–1458. 2014/07/13.
33.
MatheveTHodgesPDanneelsL. The role of back muscle dysfunctions in chronic low back pain: state-of-the-art and clinical implications. J Clin Med2023; 12: 5510. 2023/09/09.
34.
ThompsonSJChumakovIFarhoodGK, et al.[Pre-print] Effects of physical exercise training on chronic low back pain are mediated by changes in frontostriatal connectivity and gene expression. 2024 2024/12/12. DOI: 10.31219/osf.io/9jhcq.
35.
BergevinMBendasABobeufF, et al.Unraveling the pain trajectory in chronic low back pain patients during a physical exercise training program. J Sci Med Sport2025; 29: 42–50. 2025/08/03.
36.
Angarita-FonsecaAPagéMGMelotoCB, et al.The Canadian version of the national institutes of health minimum dataset for chronic low back pain research: reference values from the Quebec low back pain study. PAIN2023; 164: 325–335.
37.
LacasseARoyJSParentAJ, et al.The Canadian minimum dataset for chronic low back pain research: a cross-cultural adaptation of the national institutes of health task force research standards. CMAJ Open2017; 5: E237–e248. 2017/04/13.
38.
MayhewJLPrinsterJLWareJS, et al.Muscular endurance repetitions to predict bench press strength in men of different training levels. J Sports Med Phys Fitness1995; 35: 108–113. 1995/06/01.
39.
RosensteinBRyeMRoussacA, et al.Comparison of combined motor control training and isolated extensor strengthening versus general exercise on lumbar paraspinal muscle health and associations with patient-reported outcome measures in chronic low back pain patients: a randomized controlled trial. Global Spine J2025; 15: 21925682251324490. 2025/03/12.
40.
RosensteinBMontpetitCVaillancourtN, et al.Aquatic exercise versus standard care on paraspinal muscle morphology and function in chronic low back pain patients: a randomized controlled trial. Sci Rep2025; 15: 15798. 2025/05/07.
41.
BerryDBPadwalJJohnsonS, et al.Methodological considerations in region of interest definitions for paraspinal muscles in axial MRIs of the lumbar spine. BMC Musculoskelet Disord2018; 19: 135. 2018/05/08.
42.
CrawfordRJCornwallJAbbottR, et al.Manually defining regions of interest when quantifying paravertebral muscles fatty infiltration from axial magnetic resonance imaging: a proposed method for the lumbar spine with anatomical cross-reference. BMC Musculoskelet Disord2017; 18: 25. 2017/01/21.
43.
LamothCJStinsJFPontM, et al.Effects of attention on the control of locomotion in individuals with chronic low back pain. J Neuroeng Rehabil2008; 5: 13. 2008/04/29.
44.
ButeraKAFoxEJBishopMD, et al.Empirically derived back pain subgroups differentiated walking performance, pain, and disability. Pain2021; 162: 1806–1815. 2020/12/12.
45.
KoVNaylorJMHarrisIA, et al.The six-minute walk test is an excellent predictor of functional ambulation after total knee arthroplasty. BMC Musculoskelet Disord2013; 14: 145. 2013/04/27.
46.
PankoffBOverendTLucyD, et al.Validity and responsiveness of the 6 min walk test for people with fibromyalgia. J Rheumatol2000; 27: 2666–2670. 2000/11/28.
47.
JakobssonMBrisbyHGutkeA, et al.One-minute stair climbing, 50-foot walk, and timed up-and-go were responsive measures for patients with chronic low back pain undergoing lumbar fusion surgery. BMC Musculoskelet Disord2019; 20: 137. 2019/04/01.
48.
JakobssonMGutkeAMokkinkLB, et al.Level of evidence for reliability, validity, and responsiveness of physical capacity tasks designed to assess functioning in patients with low back pain: a systematic review using the COSMIN standards. Phys Ther2019; 99: 457–477. 2018/12/20.
49.
ButlerHLKozeyJW. The effect of load and posture on load estimations during a simulated lifting task in female workers. Int J Ind Ergon2003; 31: 331–341.
50.
OsmanABarriosFXGutierrezPM, et al.The pain catastrophizing scale: further psychometric evaluation with adult samples. J Behav Med2000; 23: 351–365. 2000/09/14.
51.
GeorgeSZValenciaCBeneciukJM. A psychometric investigation of fear-avoidance model measures in patients with chronic low back pain. J Orthop Sports Phys Ther2010; 40: 197–205. 2010/04/02.
52.
LuoXGeorgeMLKakourasI, et al.Reliability, validity, and responsiveness of the short form 12-item survey (SF-12) in patients with back pain. Spine (Phila Pa 1976)2003; 28: 1739–1745. 2003/08/05.
53.
DavidsonMKeatingJL. A comparison of five low back disability questionnaires: reliability and responsiveness. Phys Ther2002; 82: 8–24. 2002/01/11.
54.
FritzJMIrrgangJJ. A comparison of a modified oswestry low back pain disability questionnaire and the Quebec back pain disability scale. Phys Ther2001; 81: 776–788. 2001/02/15.
55.
ChildsJDPivaSRFritzJM. Responsiveness of the numeric pain rating scale in patients with low back pain. Spine (Phila Pa 1976)2005; 30: 1331–1334. 2005/06/02.
56.
SkapinakisP. Spielberger state-trait anxiety inventory. In: MichalosAC (eds) Encyclopedia of quality of life and well-being research. Dordrecht: Springer Netherlands, 2014, pp.6261–6264.
57.
DietrichNLuomajokiHHotz-BoendermakerS. The association between mechanical temporal summation, state anxiety at baseline, and persistent low back pain: a 12-month prospective cohort study. BMC Musculoskelet Disord2023; 24: 957. 2023/12/09.
58.
CohenJ. Statistical Power Analysis for the Behavioral Sciences. New York: L. Erlbaum Associates, 1988.
59.
ZhangSKGuMLZhangT, et al.Effects of exercise therapy on disability, mobility, and quality of life in the elderly with chronic low back pain: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res2023; 18: 513. 2023/07/20.
60.
LiYYanLHouL, et al.Exercise intervention for patients with chronic low back pain: a systematic review and network meta-analysis. Front Public Health2023; 11: 1155225. 2023/11/30.
61.
Martinez-CalderonJFlores-CortesMMorales-AsencioJM, et al.Conservative interventions reduce fear in individuals with chronic low back pain: a systematic review. Arch Phys Med Rehabil2020; 101: 329–358. 2019/09/02.
62.
JadhakhanFSobeihRFallaD. Effects of exercise/physical activity on fear of movement in people with spine-related pain: a systematic review. Front Psychol2023; 14: 1213199. 2023/08/14.
63.
HanelJOwenPJHeldS, et al.Effects of exercise training on fear-avoidance in pain and pain-free populations: systematic review and meta-analysis. Sports Med2020; 50: 2193–2207. 2020/09/19.
64.
OthmanRDassanayakeSJayakaranP, et al.Relationships between psychological, social, physical activity, and sleep measures and somatosensory function in individuals with spinal pain: a systematic review and meta-analysis. Clin J Pain2020; 36: 124–134. 2019/11/26.
65.
NicholasMK. The pain self-efficacy questionnaire: taking pain into account. Eur J Pain2007; 11: 153–163. 2006/02/01.
66.
CraftLLPernaFM. The benefits of exercise for the clinically depressed. Prim Care Companion J Clin Psychiatry2004; 6: 104–111. 2004/09/14.
67.
KardashLWallCLFlackM, et al.The role of pain self-efficacy and pain catastrophising in the relationship between chronic pain and depression: a moderated mediation model. PLoS One2024; 19: e0303775. 2024/05/23.
68.
SeyedhoseinpoorTTaghipourMDadgooM, et al.Alteration of lumbar muscle morphology and composition in relation to low back pain: a systematic review and meta-analysis. Spine J2022; 22: 660–676. 2021/11/01.
FortinMVidemanTGibbonsLE, et al.Paraspinal muscle morphology and composition: a 15-yr longitudinal magnetic resonance imaging study. Med Sci Sports Exerc2014; 46: 893–901. 2013/10/05.
71.
SaleemSAslamHMRehmaniMA, et al.Lumbar disc degenerative disease: disc degeneration symptoms and magnetic resonance image findings. Asian Spine J2013; 7: 322–334. 2013/12/20.
72.
CrawfordRJFilliLElliottJ, et al.Age-and level-dependence of fatty infiltration in lumbar paravertebral muscles of healthy volunteers. Am J Neuroradiol2016; 37: 742–748.
73.
WelchNMoranKAntonyJ, et al.The effects of a free-weight-based resistance training intervention on pain, squat biomechanics and MRI-defined lumbar fat infiltration and functional cross-sectional area in those with chronic low back. BMJ Open Sport Exerc Med2015; 1: e000050. 2016/12/03.
74.
WesselinkEOPoolJJMMollemaJ, et al.Is fatty infiltration in paraspinal muscles reversible with exercise in people with low back pain? A systematic review. Eur Spine J2023; 32: 787–796. 2022/12/03.
75.
HodgesPWBaileyJFFortinM, et al.Paraspinal muscle imaging measurements for common spinal disorders: review and consensus-based recommendations from the ISSLS degenerative spinal phenotypes group. Eur Spine J2021; 30: 3428–3441. 2021/09/21.
76.
FallaDHodgesPW. Individualized exercise interventions for spinal pain. Exerc Sport Sci Rev2017; 45: 105–115. 2017/01/17.
77.
WesselinkEde RaaijEPevenageP, et al.Fear-avoidance beliefs are associated with a high fat content in the erector spinae: a 1.5 tesla magnetic resonance imaging study. Chiropr Man Therap2019; 27: 14. 2019/03/29.
78.
PintoSMBoghraSBMacedoLG, et al.Does motor control exercise restore normal morphology of lumbar Multifidus muscle in people with low back pain? - A systematic review. J Pain Res2021; 14: 2543–2562. 2021/08/28.
79.
BerryDBPadwalJJohnsonS, et al.The effect of high-intensity resistance exercise on lumbar musculature in patients with low back pain: a preliminary study. BMC Musculoskelet Disord2019; 20: 290. 2019/06/19.
80.
KalichmanLCarmeliEBeenE. The association between imaging parameters of the paraspinal muscles, spinal degeneration, and low back pain. Biomed Res Int2017; 2017: 2562957. 2017/04/15.
81.
FischerMANanzDShimakawaA, et al.Quantification of muscle fat in patients with low back pain: comparison of multi-echo MR imaging with single-voxel MR spectroscopy. Radiology2013; 266: 555–563. 2012/11/13.
82.
TeichtahlAJUrquhartDMWangY, et al.Fat infiltration of paraspinal muscles is associated with low back pain, disability, and structural abnormalities in community-based adults. Spine J2015; 15: 1593–1601. 2015/04/02.
83.
MatheveTTimmermansADanneelsL, et al.Task-Specific perceived harmfulness predicts protective movement behaviour in chronic low back pain. J Clin Med2024; 13: 5025.
84.
D'HoogeRCagnieBCrombezG, et al.Increased intramuscular fatty infiltration without differences in lumbar muscle cross-sectional area during remission of unilateral recurrent low back pain. Man Ther2012; 17: 584–588. 2012/07/13.
85.
AiraksinenOHernoAKaukanenE, et al.Density of lumbar muscles 4 years after decompressive spinal surgery. Eur Spine J1996; 5: 193–197. 1996/01/01.
86.
SchlaegerSInhuberSRohrmeierA, et al.Association of paraspinal muscle water-fat MRI-based measurements with isometric strength measurements. Eur Radiol2019; 29: 599–608. 2018/07/18.
87.
DieckmeyerMInhuberSSchlaegerS, et al.Texture features of proton density fat fraction maps from chemical shift encoding-based MRI predict paraspinal muscle strength. Diagnostics (Basel)2021; 11: 239. 2021/02/10.
