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Effect of Core Stability Exercises With and Without the Alexander Ergonomic Technique on Kinesiophobia, Anxiety, and Depression in Women with Chronic Non-Specific Low Back Pain
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Ali Yalfani    , Masoud Azizian * , Fatemeh Ghasemali , Mryam Bashiri |
| , masoudazizian72@yahoo.com |
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Abstract: (5 Views) |
Background and Objective
Low back pain is one of the most common musculoskeletal disorders affecting humans, and nearly everyone experiences it at least once during their lifetime. Low back pain can negatively affect general health and significantly reduce patients’ quality of life. In addition, it imposes substantial economic and social burdens on affected individuals. The World Health Organization estimates that approximately 60–70% of adults worldwide experience low back pain at least once in their lifetime, and nearly 10% may develop chronic low back pain. Furthermore, existing evidence suggests that low back pain is more prevalent in women than in men.
Chronic non-specific low back pain, in addition to its physical consequences, is associated with considerable psychological disturbances. Studies have shown that patients with this condition often experience higher levels of kinesiophobia, anxiety, and depression, all of which may negatively influence recovery and return to daily activities. Epidemiological evidence further indicates that the prevalence of psychological disorders, particularly anxiety and depression, among individuals with chronic musculoskeletal pain, including low back pain, ranges from 20% to 50%. Researchers increasingly emphasize that addressing psychological factors and fear of movement is essential when designing rehabilitation programs for patients with chronic non-specific low back pain, as these factors play a critical role in symptom severity and functional limitations. Among these factors, pain intensity is considered a key contributor that is directly associated with worsening psychological distress, including anxiety and depression. Increased pain intensity may reinforce fear of movement and drive patients into a vicious cycle of pain, activity avoidance, and functional disability. Accordingly, the present study was designed to investigate the effects of combined core stability training and the Alexander technique on kinesiophobia and psychological factors, including anxiety and depression, in women with chronic non-specific low back pain. The hypothesis of this randomized controlled clinical trial was that eight weeks of combined core stability training and Alexander technique–based ergonomic intervention would lead to significant reductions in kinesiophobia, anxiety, and depression among women with chronic non-specific low back pain.
Methods
The present study was an applied research project in terms of purpose and a quasi-experimental study with a pre-test/post-test design in terms of data collection. This investigation was conducted as a randomized controlled clinical trial in which assessors were blinded to group allocation.
A total of 63 women diagnosed with chronic non-specific low back pain (CNSLBP), aged 30–50 years, participated in this study. Participants were recruited using a convenience sampling method from women referred to medical centers, physiotherapy clinics, and rehabilitation centers. Following initial screening and assessment of eligibility criteria, qualified participants were enrolled in the study. Participants were then randomly allocated into three equal groups (n = 21 per group) using a computerized random number generator: (1) combined training group (core stability training plus Alexander technique), (2) core stability training group, and (3) control group.Sample size estimation was performed using G*Power software (version 3.1) based on one-way analysis of variance (One-Way ANOVA), considering an effect size of 0.80, a significance level of 0.05, and statistical power of 0.95. Based on these assumptions, the minimum required sample size was estimated to be 18 participants per group. To account for potential dropout during the intervention period, the final sample size was increased to 63 participants (21 participants in each group) to ensure adequate statistical power. To ensure methodological rigor and transparent reporting, this randomized controlled trial was conducted in accordance with the CONSORT 2010 guidelines.
Results
Demographic characteristics of the participants are presented in Table 1. The Shapiro–Wilk test indicated that all demographic variables were normally distributed across the three groups (p > 0.05). Furthermore, one-way ANOVA revealed no significant differences among the control, combined training, and core stability groups in baseline demographic characteristics, including age, height, weight, body composition, or study outcome variables at pre-intervention assessment (p > 0.05). The results of one-way ANOVA demonstrated significant between-group differences following the 8-week rehabilitation intervention in kinesiophobia (F = 99.498, p < 0.001, ηp² = 0.768), anxiety (F = 146.120, p < 0.001, ηp² = 0.830), and depression (F = 72.626, p < 0.001, ηp² = 0.708), with medium to large effect sizes. To further examine pairwise group differences, Tukey post hoc analysis was performed. The results indicated significant differences between both intervention groups (combined training and core stability training) and the control group across all three outcome measures (p < 0.001). Moreover, significant differences were observed between the combined training group and the core stability training group in improving kinesiophobia, anxiety, and depression (p = 0.004), with the combined training group demonstrating superior effectiveness compared with core stability training alone.
Conclusion
Adding Alexander technique–based training to a core stability exercise program, compared with core stability training alone, resulted in greater improvements in psychological outcomes, including anxiety, depression, and kinesiophobia, in women with chronic non-specific low back pain. These findings support the effectiveness of combined rehabilitation approaches that simultaneously target biomechanical, neuromuscular, and psychological components. The results of the present study suggest that integrating motor re-education strategies and functional movement correction with core stability exercises may significantly enhance the effectiveness of rehabilitation protocols for patients with chronic non-specific low back pain. This combined approach may improve psychological outcomes by reducing unnecessary muscular tension, enhancing body awareness, correcting maladaptive movement patterns, and decreasing pain-related avoidance behaviors. Therefore, incorporating the ergonomic principles of the Alexander technique and motor re-education strategies as complementary interventions alongside conventional rehabilitation programs is recommended for patients with chronic non-specific low back pain.
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| Keywords: Chronic non-specific low back pain, core stability, lumbopelvic stabilization, Rehabilitation, Women |
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Type of Study: Research |
Subject:
medicine, paraclinic
Received: 2026/06/26 | Revised: 2026/08/19 | Accepted: 2026/08/19
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Ethics code: IR.BASU.REC.1404.013
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