Research Article| Volume 103, 105902, March 2023

Physical clinical care and artificial-intelligence-guided core resistance training improve endurance and patient-reported outcomes in subjects with lower back pain


      • Low back pain continues to be a major cost and disability burden on the medical community.
      • Artificial intelligence guided exercise improved function and outcomes in low back pain patients.
      • Control patients failed to exhibit improvements over the 8-week period.
      • Artificial intelligence guided exercise offers a supplement to clinical care for low back pain.



      Low back pain is an extremely prevalent issue with an extensive impact, ranging from decreased quality of life to lost years of productivity. Many interventions have been developed to alleviate chronic lower back pain, yet it remains a widespread problem. The objective of this study was to examine the role of artificial intelligence guided resistance training relative to clinical variables in subjects experiencing lower back pain.


      69 out of 108 enrolled and 92 accrued subjects completed the 8-week intervention. Subjects were randomized into four groups (Control, Training, Clinical, or Combined). The Training cohort received supervised artificial-intelligence-guided core-focused resistance training while the Clinical group received clinical care. The Combined group received both clinical care and artificial-intelligence-guided training and the Control group received no treatment. Participants were evaluated using functional testing and patient-reported outcomes at baseline, 4 weeks, and 8 weeks.


      In the clinical tests, the Clinical and Combined cohorts showed increased total time for isometric extensor endurance and the Clinical cohort increased total distance traveled in the 6-min walk test at 8 weeks. The Training, Clinical, and Combined groups showed improvements in Patient-reported outcomes after 8 weeks. Most of the significant improvements were only seen at the 8-week evaluation for both the clinical evaluations and Patient-reported outcomes. The Control group did not show significant improvements in any outcome measures.


      The present data indicate that core-focused interventions, including artificial-intelligence-guided moderate-resistance exercise, can increase objective functional outcomes and patient satisfaction using Patient-reported outcomes in individuals with lower back pain.


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        • Amirdelfan K.
        • Gliner B.E.
        • Kapural L.
        • Sitzman B.T.
        • Vallejo R.
        • Yu C.
        • Caraway D.
        • Rotte A.
        • Province-Azalde R.
        • Krames E.
        A proposed definition of remission from chronic pain, based on retrospective evaluation of 24-month outcomes with spinal cord stimulation.
        Postgrad. Med. 2019; 131: 278-286
        • Areeudomwong P.
        • Buttagat V.
        Comparison of Core stabilisation exercise and proprioceptive neuromuscular facilitation training on pain-related and neuromuscular response outcomes for chronic low Back pain: a randomised controlled trial.
        The Malaysian J. Med. Sci.: MJMS. 2019; 26: 77-89
        • Askew R.L.
        • Cook K.F.
        • Revicki D.A.
        • Cella D.
        • Amtmann D.
        Evidence from diverse clinical populations supported clinical validity of PROMIS pain interference and pain behavior.
        J. Clin. Epidemiol. 2016; 73: 103-111
        • ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories
        ATS statement: guidelines for the six-minute walk test.
        Am. J. Respir. Crit. Care Med. 2002; 166: 111-117
        • Bekkering G.E.
        • Hendriks H.J.M.
        • Koes B.W.
        • Oostendorp R.A.B.
        • Ostelo R.W.J.G.
        • Thomassen J.M.C.
        • Van Tulder M.W.
        Dutch physiotherapy guidelines for low back pain.
        Physiotherapy. 2003; 89: 82-96
        • Bohannon R.W.
        • Crouch R.
        Minimal clinically important difference for change in 6-minute walk test distance of adults with pathology: a systematic review.
        J. Eval. Clin. Pract. 2017; 23: 377-381
        • Bonnette S.
        • DiCesare C.A.
        • Kiefer A.W.
        • Riley M.A.
        • Barber Foss K.D.
        • Thomas S.
        • Kitchen K.
        • Diekfuss J.A.
        • Myer G.D.
        Injury risk factors integrated into self-guided real-time biofeedback improves high-risk biomechanics.
        J. Sport Rehabil. 2019; 28: 831-839
        • Boonstra A.M.
        • Schiphorst Preuper H.R.
        • Reneman M.F.
        • Posthumus J.B.
        • Stewart R.E.
        Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain.
        Int. J. Rehabilit. Res. Int. Zeitschrift fur Rehabilit. Revue Int. de Rech. de Readapt. 2008; 31: 165-169
        • Brodke D.J.
        • Saltzman C.L.
        • Brodke D.S.
        PROMIS for Orthopaedic outcomes measurement.
        J. American Acad. Orthopaed. Surg. 2016; 24: 744-749
        • Chang W.D.
        • Lin H.Y.
        • Lai P.T.
        Core strength training for patients with chronic low back pain.
        J. Phys. Ther. Sci. 2015; 27: 619-622
        • Chiarotto A.
        • Maxwell L.J.
        • Ostelo R.W.
        • Boers M.
        • Tugwell P.
        • Terwee C.B.
        Measurement properties of visual analogue scale, numeric rating scale, and pain severity subscale of the brief pain inventory in patients with low Back pain: a systematic review.
        J. Pain. 2019; 20: 245-263
        • Christie H.J.
        • Kumar S.
        • Warren S.A.
        Postural aberrations in low back pain.
        Arch. Phys. Med. Rehabil. 1995; 76: 218-224
        • Copay A.G.
        • Glassman S.D.
        • Subach B.R.
        • Berven S.
        • Schuler T.C.
        • Carreon L.Y.
        Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry disability index, medical outcomes study questionnaire short form 36, and pain scales.
        The Spine J. : Off. J. North American Spine Soc. 2008; 8: 968-974
        • Coulombe B.J.
        • Games K.E.
        • Neil E.R.
        • Eberman L.E.
        Core stability exercise versus general exercise for chronic low Back pain.
        J. Athl. Train. 2017; 52: 71-72
        • Crombez G.
        • Vlaeyen J.W.
        • Heuts P.H.
        • Lysens R.
        Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability.
        Pain. 1999; 80: 329-339
        • Cruz-Montecinos C.
        • Núñez-Cortés R.
        • Guzmán-González B.
        • Andersen L.L.
        • García-Massó X.
        • Calatayud J.
        The relevance of dual tasking for improving trunk muscle endurance after Back surgery.
        Arch. Phys. Med. Rehabil. 2021; 102: 463-469
        • Demoulin C.
        • Vanderthommen M.
        • Duysens C.
        • Crielaard J.M.
        Spinal muscle evaluation using the Sorensen test: a critical appraisal of the literature.
        Joint Bone Spine. 2006; 73: 43-50
        • Diekfuss J.A.
        • Grooms D.R.
        • Bonnette S.
        • DiCesare C.A.
        • Thomas S.
        • MacPherson R.P.
        • Ellis J.D.
        • Kiefer A.W.
        • Riley M.A.
        • Schneider D.K.
        • Gadd B.
        • Kitchen K.
        • Barber Foss K.D.
        • Dudley J.A.
        • Yuan W.
        • Myer G.D.
        Real-time biofeedback integrated into neuromuscular training reduces high-risk knee biomechanics and increases functional brain connectivity: a preliminary longitudinal investigation.
        Psychophysiology. 2020; 57e13545
        • Eversole J.
        • Grimm A.
        • Patel N.
        • John K.
        • Garcia A.N.
        Why measure patient experience in physical therapy?.
        Arch. Physiotherap. 2021; 11: 11
        • Feng D.
        • Laurel F.
        • Castille D.
        • McCormick A.
        • Held S.
        Reliability, construct validity, and measurement invariance of the PROMIS physical function 8b-adult short form v2.0.
        Qual. Life Res. Int. J. Qual. Life Asp. Treat. Care Rehab. 2020; 29: 3397-3406
        • Ford K.R.
        • DiCesare C.A.
        • Myer G.D.
        • Hewett T.E.
        Real-time biofeedback to target risk of anterior cruciate ligament injury: a technical report for injury prevention and rehabilitation.
        J. Sport Rehabil. 2015; 24: 2013-2038
        • Foster N.E.
        • Anema J.R.
        • Cherkin D.
        • Chou R.
        • Cohen S.P.
        • Gross D.P.
        • Ferreira P.H.
        • Fritz J.M.
        • Koes B.W.
        • Peul W.
        • Turner J.A.
        • Maher C.G.
        • Lancet Low Back Pain Series Working Group
        Prevention and treatment of low back pain: evidence, challenges, and promising directions.
        Lancet (London, England). 2018; 391: 2368-2383
        • Freburger J.K.
        • Holmes G.M.
        • Agans R.P.
        • Jackman A.M.
        • Darter J.D.
        • Wallace A.S.
        • Castel L.D.
        • Kalsbeek W.D.
        • Carey T.S.
        The rising prevalence of chronic low back pain.
        Arch. Intern. Med. 2009; 169: 251-258
        • French H.P.
        • Keogan F.
        • Gilsenan C.
        • Waldron L.
        • O’Connell P.
        Measuring patient satisfaction with exercise therapy for knee osteoarthritis: evaluating the utility of the physiotherapy outpatient survey.
        Musculoskelet. Care. 2010; 8: 61-67
        • Geneen L.J.
        • Moore R.A.
        • Clarke C.
        • Martin D.
        • Colvin L.A.
        • Smith B.H.
        Physical activity and exercise for chronic pain in adults: an overview of Cochrane reviews.
        The Cochrane Database Sys. Rev. 2017; 4: CD011279
        • Ghroubi S.
        • Jribi S.
        • Jdidi J.
        • Yahia A.
        • Elleuch W.
        • Chaaben M.
        • Dammak J.
        • Elleuch M.H.
        Study of the validity and reproducibility of the Biering-Sorensen test in chronic low back pain.
        Ann. Phys. Rehabilitat. Med. 2015; 58e88
        • Harkey L.C.
        • Jung S.M.
        • Newton E.R.
        • Patterson A.
        Patient satisfaction with telehealth in rural settings: a systematic review.
        Int. J. Telerehabilit. 2020; 12: 53-64
        • Harris P.A.
        • Taylor R.
        • Thielke R.
        • Payne J.
        • Gonzalez N.
        • Conde J.G.
        Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support.
        J. Biomed. Inform. 2009; 42: 377-381
        • Hong J.H.
        • Kim H.D.
        • Shin H.H.
        • Huh B.
        Assessment of depression, anxiety, sleep disturbance, and quality of life in patients with chronic low back pain in Korea.
        Korean J. Anesthesiol. 2014; 66: 444-450
        • Hultman G.
        • Nordin M.
        • Saraste H.
        • Ohlsèn H.
        Body composition, endurance, strength, cross-sectional area, and density of MM erector spinae in men with and without low back pain.
        J. Spinal Disord. 1993; 6: 114-123
        • Hurwitz E.L.
        • Randhawa K.
        • Yu H.
        • Côté P.
        • Haldeman S.
        The global spine care initiative: a summary of the global burden of low back and neck pain studies.
        Eur. Spine J. : Off. Pub. Eur. Spine Soc., Eur. Spinal Deformity Soc. Eur. Sect. Cervical Spine Res. Soc. 2018; 27: 796-801
        • Husky M.M.
        • Ferdous Farin F.
        • Compagnone P.
        • Fermanian C.
        • Kovess-Masfety V.
        Chronic back pain and its association with quality of life in a large French population survey.
        Health Qual. Life Outcomes. 2018; 16: 195
        • Jenkins N.W.
        • Parrish J.M.
        • Cha E.
        • Lynch C.P.
        • Sayari A.J.
        • Geoghegan C.E.
        • Jadczak C.N.
        • Mohan S.
        • Singh K.
        Validation of PROMIS physical function in MIS TLIF: 2-year follow-up.
        Spine. 2020; 45: E1516-E1522
        • Kato S.
        • Murakami H.
        • Demura S.
        • Yoshioka K.
        • Shinmura K.
        • Yokogawa N.
        • Igarashi T.
        • Yonezawa N.
        • Shimizu T.
        • Tsuchiya H.
        Abdominal trunk muscle weakness and its association with chronic low back pain and risk of falling in older women.
        BMC Musculoskelet. Disord. 2019; 20: 273
        • Katz J.N.
        Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.
        J. Bone Joint Surgery American. 2006; 88: 21-24
        • Kell R.T.
        • Asmundson G.J.
        A comparison of two forms of periodized exercise rehabilitation programs in the management of chronic nonspecific low-back pain.
        J. Strength Cond. Res. 2009; 23: 513-523
        • Keller A.
        • Hellesnes J.
        • Brox J.I.
        Reliability of the isokinetic trunk extensor test, Biering-Sørensen test, and Astrand bicycle test: assessment of intraclass correlation coefficient and critical difference in patients with chronic low back pain and healthy individuals.
        Spine. 2001; 26: 771-777
        • Khutok K.
        • Janwantanakul P.
        • Jensen M.P.
        • Kanlayanaphotporn R.
        Responsiveness of the PROMIS-29 scales in individuals with chronic low Back pain.
        Spine. 2021; 46: 107-113
        • Koes B.W.
        • van Tulder M.W.
        • Thomas S.
        Diagnosis and treatment of low back pain.
        BMJ (Clinical research ed.). 2006; 332: 1430-1434
        • Kruse C.S.
        • Krowski N.
        • Rodriguez B.
        • Tran L.
        • Vela J.
        • Brooks M.
        Telehealth and patient satisfaction: a systematic review and narrative analysis.
        BMJ Open. 2017; 7e016242
        • Kumar T.
        • Kumar S.
        • Nezamuddin M.
        • Sharma V.P.
        Efficacy of core muscle strengthening exercise in chronic low back pain patients.
        J. Back Musculosk. Rehabilit. 2015; 28: 699-707
        • Latimer J.
        • Maher C.G.
        • Refshauge K.
        • Colaco I.
        The reliability and validity of the Biering–Sorensen test in asymptomatic subjects and subjects reporting current or previous nonspecific low back pain.
        Spine. 1999; 24: 2085
        • Liu N.
        • Huang R.
        • Baldacchino T.
        • Sud A.
        • Sud K.
        • Khadra M.
        • Kim J.
        Telehealth for noncritical patients with chronic diseases during the COVID-19 pandemic.
        J. Med. Internet Res. 2020; 22e19493
        • Love A.
        • Leboeuf C.
        • Crisp T.C.
        Chiropractic chronic low back pain sufferers and self-report assessment methods. Part I. a reliability study of the visual analogue scale, the pain drawing and the McGill pain questionnaire.
        J. Manipulative Physiol. Ther. 1989; 12: 21-25
        • Lundberg M.
        • Styf J.
        • Jansson B.
        On what patients does the Tampa scale for Kinesiophobia fit?.
        Physiotherap. Theory Prac. 2009; 25: 495-506
        • Mannion A.F.
        • Müntener M.
        • Taimela S.
        • Dvorak J.
        A randomized clinical trial of three active therapies for chronic low back pain.
        Spine. 1999; 24: 2435-2448
        • Mannion A.F.
        • Junge A.
        • Taimela S.
        • Müntener M.
        • Lorenzo K.
        • Dvorak J.
        Active therapy for chronic low back pain: part 3. Factors influencing self-rated disability and its change following therapy.
        Spine. 2001; 26: 920-929
        • Meucci R.D.
        • Fassa A.G.
        • Faria N.M.
        Prevalence of chronic low back pain: systematic review.
        Rev. Saude Publica. 2015; 49: 1
        • Nambi G.
        • Abdelbasset W.K.
        • Alqahtani B.A.
        • Alrawaili S.M.
        • Abodonya A.M.
        • Saleh A.K.
        Isokinetic back training is more effective than core stabilization training on pain intensity and sports performances in football players with chronic low back pain: a randomized controlled trial.
        Medicine. 2020; 99e20418
        • Newcomer K.L.
        • Jacobson T.D.
        • Gabriel D.A.
        • Larson D.R.
        • Brey R.H.
        • An K.N.
        Muscle activation patterns in subjects with and without low back pain.
        Arch. Phys. Med. Rehabil. 2002; 83: 816-821
        • Nicolaisen T.
        • Jørgensen K.
        Trunk strength, back muscle endurance and low-back trouble.
        Scand. J. Rehabil. Med. 1985; 17: 121-127
        • Ostelo R.W.
        • de Vet H.C.
        Clinically important outcomes in low back pain.
        Best Pract. Res. Clin. Rheumatol. 2005; 19: 593-607
        • Page P.
        Beyond statistical significance: clinical interpretation of rehabilitation research literature.
        Int. J. Sports Phys. Therap. 2014; 9: 726-736
        • Parker S.L.
        • Mendenhall S.K.
        • Shau D.N.
        • Adogwa O.
        • Anderson W.N.
        • Devin C.J.
        • McGirt M.J.
        Minimum clinically important difference in pain, disability, and quality of life after neural decompression and fusion for same-level recurrent lumbar stenosis: understanding clinical versus statistical significance.
        J. Neurosurg. Spine. 2012; 16: 471-478
        • Puente-Maestu L.
        • Sanz M.L.
        • Sanz P.
        • Cubillo J.M.
        • Mayol J.
        • Casaburi R.
        Comparison of effects of supervised versus self-monitored training programmes in patients with chronic obstructive pulmonary disease.
        Eur. Respir. J. 2000; 15: 517-525
        • Rainville J.
        • Hartigan C.
        • Martinez E.
        • Limke J.
        • Jouve C.
        • Finno M.
        Exercise as a treatment for chronic low back pain.
        Spine J. : Off. J. North American Spine Soc. 2004; 4: 106-115
        • Roelofs J.
        • van Breukelen G.
        • Sluiter J.
        • Frings-Dresen M.
        • Goossens M.
        • Thibault P.
        • Boersma K.
        • Vlaeyen J.
        Norming of the Tampa scale for Kinesiophobia across pain diagnoses and various countries.
        Pain. 2011; 152: 1090-1095
        • Sadosky A.B.
        • Taylor-Stokes G.
        • Lobosco S.
        • Pike J.
        • Ross E.
        Relationship between self-reported low-back pain severity and other patient-reported outcomes: results from an observational study.
        J. Spinal Disord. Tech. 2013; 26: 8-14
        • Schalet B.D.
        • Hays R.D.
        • Jensen S.E.
        • Beaumont J.L.
        • Fries J.F.
        • Cella D.
        Validity of PROMIS physical function measured in diverse clinical samples.
        J. Clin. Epidemiol. 2016; 73: 112-118
        • Sherman K.J.
        • Cherkin D.C.
        • Connelly M.T.
        • Erro J.
        • Savetsky J.B.
        • Davis R.B.
        • Eisenberg D.M.
        Complementary and alternative medical therapies for chronic low back pain: what treatments are patients willing to try?.
        BMC Complement. Altern. Med. 2004; 4: 9
        • Smith C.E.
        • Dauz E.R.
        • Clements F.
        • Puno F.N.
        • Cook D.
        • Doolittle G.
        • Leeds W.
        Telehealth services to improve nonadherence: a placebo-controlled study.
        Telemed. J. e-health : Off. J. American Telemed. Assoc. 2006; 12: 289-296
        • Sugimoto D.
        • Myer G.D.
        • Bush H.M.
        • Klugman M.F.
        • Medina McKeon J.M.
        • Hewett T.E.
        Compliance with neuromuscular training and anterior cruciate ligament injury risk reduction in female athletes: a meta-analysis.
        J. Athl. Train. 2012; 47: 714-723
        • Sugimoto D.
        • Myer G.D.
        • Foss K.D.
        • Hewett T.E.
        Dosage effects of neuromuscular training intervention to reduce anterior cruciate ligament injuries in female athletes: meta- and sub-group analyses.
        Sports Med. (Auckland, N.Z.). 2014; 44: 551-562
        • Takeyachi Y.
        • Konno S.
        • Otani K.
        • Yamauchi K.
        • Takahashi I.
        • Suzukamo Y.
        • Kikuchi S.
        Correlation of low back pain with functional status, general health perception, social participation, subjective happiness, and patient satisfaction.
        Spine. 2003; 28: 1461-1467
        • Tanne D.
        • Tsabari R.
        • Chechik O.
        • Toledano A.
        • Orion D.
        • Schwammenthal Y.
        • Philips T.
        • Schwammenthal E.
        • Adler Y.
        Improved exercise capacity in patients after minor ischemic stroke undergoing a supervised exercise training program.
        The Israel Med. Assoc. J. : IMAJ. 2008; 10: 113-116
        • Tataryn N.
        • Simas V.
        • Catterall T.
        • Furness J.
        • Keogh J.
        Posterior-chain resistance training compared to general exercise and walking Programmes for the treatment of chronic low Back pain in the general population: a systematic review and Meta-analysis.
        Sports Med. - open. 2021; 7: 17
        • Thorstensson A.
        • Arvidson A.
        Trunk muscle strength and low back pain.
        Scand. J. Rehabil. Med. 1982; 14: 69-75
        • Torstensen T.A.
        • Ljunggren A.E.
        • Meen H.D.
        • Odland E.
        • Mowinckel P.
        • Geijerstam S.
        Efficiency and costs of medical exercise therapy, conventional physiotherapy, and self-exercise in patients with chronic low back pain. A pragmatic, randomized, single-blinded, controlled trial with 1-year follow-up.
        Spine. 1998; 23: 2616-2624
        • Ulger O.
        • Demirel A.
        • Oz M.
        • Tamer S.
        The effect of manual therapy and exercise in patients with chronic low back pain: double blind randomized controlled trial.
        J. Back Musculosk. Rehabilit. 2017; 30: 1303-1309
        • Vogt L.
        • Pfeifer K.
        • Banzer W.
        Neuromuscular control of walking with chronic low-back pain.
        Man. Ther. 2003; 8: 21-28
        • Wertli M.M.
        • Rasmussen-Barr E.
        • Held U.
        • Weiser S.
        • Bachmann L.M.
        • Brunner F.
        Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: a systematic review.
        The Spine J. : Off. J. North American Spine Soc. 2014; 14: 2658-2678
        • Wertli M.M.
        • Rasmussen-Barr E.
        • Weiser S.
        • Bachmann L.M.
        • Brunner F.
        The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review.
        The Spine J. : Off. J. North American Spine Soc. 2014; 14: 816-836.e4
        • Wijeysundera D.N.
        • Johnson S.R.
        How much better is good enough?: patient-reported outcomes, minimal clinically important differences, and patient acceptable symptom states in perioperative research.
        Anesthesiology. 2016; 125: 7-10
        • Wu A.
        • March L.
        • Zheng X.
        • Huang J.
        • Wang X.
        • Zhao J.
        • Blyth F.M.
        • Smith E.
        • Buchbinder R.
        • Hoy D.
        Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the global burden of disease study 2017.
        Ann. Trans. Med. 2020; 8: 299