The effect of lumbar stabilization and stretching exercises on pain, disability, and characteristics of the lumbar paraspinal muscles in chronic nonspecific low back pain: a randomized controlled trial.

The effect of lumbar stabilization and stretching exercises on pain, disability, and characteristics of the lumbar paraspinal muscles in chronic nonspecific low back pain: a randomized controlled trial - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. 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Learn more: PMC Disclaimer | PMC Copyright Notice J Orthop Surg Res . 2026 Mar 6;21:257. doi: 10.1186/s13018-026-06758-8 Search in PMC Search in PubMed View in NLM Catalog Add to search The effect of lumbar stabilization and stretching exercises on pain, disability, and characteristics of the lumbar paraspinal muscles in chronic nonspecific low back pain: a randomized controlled trial Xiaoyu Guo Xiaoyu Guo 1 Shi’s Center of Orthopedics and Traumatology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, No. 528, Zhangheng Road, Shanghai, 201203 China Find articles by Xiaoyu Guo 1 , Wuwei Song Wuwei Song 2 Huamu Community Health Service Center of Shanghai Pudong New District, No. 96, Yulan Road, Pudong New District, Shanghai, 201204 China Find articles by Wuwei Song 2 , Lulu Zhao Lulu Zhao 3 Department of Ultrasound Medicine, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, No. 528, Zhangheng Road, Shanghai, 201203 China Find articles by Lulu Zhao 3 , Chen Wei Chen Wei 1 Shi’s Center of Orthopedics and Traumatology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, No. 528, Zhangheng Road, Shanghai, 201203 China Find articles by Chen Wei 1 , Hongsheng Zhan Hongsheng Zhan 1 Shi’s Center of Orthopedics and Traumatology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, No. 528, Zhangheng Road, Shanghai, 201203 China Find articles by Hongsheng Zhan 1, ✉ , Xiang Wang Xiang Wang 1 Shi’s Center of Orthopedics and Traumatology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, No. 528, Zhangheng Road, Shanghai, 201203 China Find articles by Xiang Wang 1, ✉ Author information Article notes Copyright and License information 1 Shi’s Center of Orthopedics and Traumatology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, No. 528, Zhangheng Road, Shanghai, 201203 China 2 Huamu Community Health Service Center of Shanghai Pudong New District, No. 96, Yulan Road, Pudong New District, Shanghai, 201204 China 3 Department of Ultrasound Medicine, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, No. 528, Zhangheng Road, Shanghai, 201203 China ✉ Corresponding author. Received 2025 Jul 15; Accepted 2026 Feb 11; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13081597  PMID: 41792820 Abstract Background Chronic nonspecific low back pain (CNSLBP) is a challenging clinical condition with a lack of specific therapies. It is closely related to impaired lumbar stability, which is associated with paraspinal muscle dysfunction. This study is designed to investigate the effect of lumbar stabilization and stretching exercises (LSSE) on pain, disability, and characteristics of lumbar paraspinal muscles in CNSLBP. Methods Eligible patients with CNSLBP were randomly allocated (1:1) to one of two groups. The control group (CON) received health education only. The intervention group (EX) received both LSSE and health education. The intervention period lasted for one month for both groups. The primary outcome was visual analog scale (VAS) score for pain intensity. Secondary outcomes included the Oswestry Disability Index (ODI) and characteristics of paraspinal muscles. Muscle stiffness (elasticity) and the cross-sectional area (CSA) of the multifidus at the lower lumbar spine were assessed using musculoskeletal ultrasound. Additionally, magnetic resonance imaging (MRI) was used to evaluate the CSA and fatty infiltration (quantified by gray-scale value) of the multifidus and erector spinae muscles at the lower lumbar spine. All assessments were conducted at baseline and immediately after the 1 month intervention. Results This trial enrolled 60 CNSLBP patients. Fifty-four participants completed the study, with identical dropout rates of 10% (3/30). There were no significant differences in age, gender, BMI, waist, duration between the two groups (All P > 0.05). After 1 month intervention, the Mann-Whitney U test revealed significantly greater improvement in both VAS and ODI scores in the EX group than in the CON group (All P < 0.05). And we performed paired-sample t-tests to evaluate the within-group differences in MRI outcomes. The results in the EX group showed significant CSA increases of multifidus at bilateral L4/L5 bilateral L4/L5 (left side: P = 0.002, Cohen’s d = 0.291cm 2 , 95% Confidence Interval (CI) − 0.245, 0.827, right side: P = 0.001, Cohen’s d = 0.326cm 2 , 95% CI − 0.211, 0.863) and L5/S1 (left side: P = 0.001, Cohen’s d = 0.427 cm 2 , 95% CI − 0.112, 0.966, right side: P < 0.001, Cohen’s d = 0.459 cm 2 , 95% CI − 0.081, 0.999), along with reduced grayscale values at bilateral L5/S1 level (left side: P = 0.003, Cohen’s d = − 0.705, 95% CI − 1.255, − 0.155; right side: P = 0.002, Cohen’s d = − 0.778, 95% CI − 1.331, − 0.225), indicating decreased fatty infiltration. Similarly, the erector spinae in the EX group showed a significant increase CSA increased at the bilateral L4/5 level (left side: P < 0.05, Cohen’s d = 0.34 cm 2 , 95% CI − 0.202, 0.872; right side: P < 0.05, Cohen’s d = 0.33 cm 2 , 95% CI − 0.211, 0.863) and L5/S1 level(left side: P < 0.05, Cohen’s d = 0.26 cm 2 , 95% CI − 0.272, 0.8; right side: P < 0.05, Cohen’s d = 0.38 cm 2 , 95% CI − 0.163, 0.913), while the gray-scale values decreased at the bilateral L5/S1 level (left side: P < 0.05, Cohen’s d = − 0.51, 95% CI − 1.052, 0.032,; right side: P < 0.05, Cohen’s d = − 0.42, 95% CI − 0.957, 0.121). And the independent samples t-test revealed a significant between-group differences for the lumbar multifidus at right L5/S1 level ( P < 0.05, Cohen’s d = 0.676cm 2 , 95% CI 0.128, 1.224). No other outcome measures showed statistically significant differences between two groups. Conclusion LSSE significantly reduced pain and improved function in patients with CNSLBP. The significant between-group increase in the CSA of the right L5/S1 multifidus suggests that muscle hypertrophy at lower lumbar levels may be one mechanism for these clinical benefits. Trial registration The trial was registered at www.chictr.org.cn , identifier ChiCTR2300068836. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-026-06758-8. Keywords: Chronic nonspecific low back pain, Multifidus, Erector spinae, Exercise, Musculoskeletal ultrasound, Randomized controlled trial Introduction Low back pain (LBP) is a prevalent clinical condition with increasing disability rates, particularly in low- and middle-income countries [ 1 , 2 ]. It ranks as the leading cause of disability worldwide [ 3 ]. The pathogenesis of LBP remains incompletely understood [ 4 ], with contemporary research categorizing it into three subtypes [ 5 ] based on etiological theories: radicular and spinal stenosis-associated LBP, specific spinal origin LBP, and nonspecific LBP. Clinically, LBP is classified by duration as acute (< 6 weeks), subacute (6–12 weeks), or chronic (> 12 weeks) [ 6 ]. 80% of individuals experience at least one episode of LBP during their lifetime [ 7 ], with 5–10% progressing to chronic LBP (> 12 weeks duration) [ 8 ]. Notably, 85% of chronic cases are classified as chronic nonspecific low back pain (CNSLBP) [ 9 , 10 ]. CNSLBP presents significant diagnostic challenges due to its poorly defined pathophysiology and the absence of definitive curative treatments [ 11 ], making it a persistent focus of clinical research. The consensus holds that non-steroidal anti-inflammatory drugs are an efficient and effective option for the management of acute LBP, particularly within the first week [ 12 ]. But there is no ‘magic bullet’ exists for CNSLBP [ 13 ]. The effectiveness of pharmacological treatments is likely overestimated in the management of CNSLBP [ 14 ], and their use is associated with potential adverse events [ 15 ]. Consequently, pharmacotherapy is no longer recommended as the initial therapeutic approach. Non-pharmacological interventions are recommended as the first-line therapy [ 16 ], with exercise, health education [ 17 ], and acupuncture [ 18 ] recognized as important strategies. Core muscle training is particularly significant. Research on core muscles has confirmed that the paraspinal muscles play a crucial role in the pathological process of CNSLBP [ 19 ]. Recent research on CNSLBP has increasingly focused on spinal stability [ 20 ]. The paraspinal muscles, particularly the multifidus and erector spinae [ 21 ], play a critical role in maintaining spinal stability. The erector spinae are the most superficial and largest of the paraspinal muscles, whose primary functions are maintaining upright posture and enabling lumbar movement [ 22 ]. In contrast, multifidus is a deep, small, segmented muscle located posterior to the spine, distributed bilaterally along the spinous processes [ 23 ]. Its primary functions include maintaining spinal segmental stability, transmitting axial loads, and protecting intervertebral discs [ 24 ]. Both of them are essential for spinal stability. Studies have confirmed that patients with CNSLBP exhibit an aberrant flexion-relaxation phenomenon compared to healthy individuals, characterized by persistent erector spinae activation during flexion [ 25 ]. This finding suggests that dysfunction of the erector spinae plays a central role in the pathogenesis of CNSLBP. Meanwhile, the multifidus, as the innermost spinal muscle, has attracted growing research interest in recent years. A systematic review showed that the multifidus CSA in chronic LBP patients is significantly smaller than in healthy controls and is positively correlated with pain levels [ 26 ]. Furthermore, compared with healthy individuals, the LBP group exhibited a higher degree of multifidus fatty infiltration [ 27 ]. Exercise therapy, as an active therapeutic approach, has been shown to yield superior clinical outcomes compared to passive interventions or even combined active-passive strategies in managing non-specific LBP [ 28 ]. Specifically, lumbar stabilization exercise can provide stabilization by strengthening the lumbar deep muscles [ 29 ]. Lumbar stabilization training requires the maintenance of trunk posture and focuses on strengthening the paraspinal muscles [ 30 ]. Studies have confirmed that this exercise is associated with enhanced lumbar stability, reduced pain, and improved function in patients with CNSLBP [ 31 , 32 ]. Lumbar stretching exercise [ 33 ] also is a common exercise to CNSLBP, which enhances muscles’ short-term flexibility by improving muscle elasticity, facet joint mobility, and somatosensory function. In addition, performing low-intensity stretching after exercise helps to reduce injury risk [ 34 ]. The clinical efficacy of integrating stretching with lumbar stabilization training for chronic LBP in pregnant women confirmed that this approach is safe and effective in alleviating pain without reported adverse events [ 35 ]. In our preliminary research and literature study, dynamic ultrasound imaging revealed that the exercises we adopted can alter the morphology of the multifidus muscle [ 36 , 37 ]. Therefore, this trial employed lumbar stabilization and stretching exercises (LSSE) regimen to investigate the effects on patients with CNSLBP, focusing on both clinical efficacy and the potential mechanism of these exercises. Methods Study design It’s a prospective, single-center randomized controlled trial conducted in accordance with the principles of the Declaration of Helsinki. The data reported from this trial compiled with the Consolidated Standards of Reporting Trials (CONSORT) statement. The trial was conducted in the Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine. The trial was approved by the ethics committee board of Shuguang Hospital and an informed consent form was signed by all participants prior to study (2022-1185-122-01, Supplementary 1). The clinical trial was registered in the Chinese Clinical Trial Registry (ChiCTR2300068836). Randomization and blinding The CONSORT diagram of participant enrollment presents in Flow chart (Fig. 1 ). Patients were randomly assigned to one of the two following groups by one researcher independently: the LSSE and health education group (the EX group) or the health education group (the CON group). Randomization was done by using a computer program that included a randomized table of numbers, which was created by an independent individual who was not involved in the recruitment and treatment of patients. Numbered cards with a random assignment and containing information about the group allocation in opaque, sealed envelopes were prepared by the independent individual. All participants were blinded to their treatment assignment. Fig. 1. Open in a new tab Flow diagram. CON the control group received health education alone, EX the intervention group received combined lumbar stabilization and stretching exercises and health education Sample size calculation Power analysis was conducted before the commencement of patient recruitment. Visual analog scale (VAS) is the primary outcome parameter and the reported minimum clinically important difference (MCID) of VAS is 2 points [ 38 ]. To achieve 90% power at a two-sided 5% significance, 25 patients were required in each group. Eventually we rounded up it to 30 considering a 20% dropout rate. Participants The patients were recruited from outpatients and inpatients of the orthopedics and traumatology department in Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine. Patients who were willing to participate in the research were evaluated to decide whether their condition met all the inclusion criteria and none of the exclusion criteria. Inclusion criteria [ 4 , 39 ] were as follows: ① Patients clinically diagnosed with CNSLBP characterized low back pain (pain localized below the costal margin and above the inferior gluteal folds [ 17 ]) recurrently persisting for ≥ 12 weeks, with exclusion of radicular pain, spinal stenosis-related pain, and specific spinal origins.② Patients aged 18–65 years. ③ Patients that have the ability to comprehend the instructions in the study. Exclusion criteria [ 40 ] were as follows: ① Patients with specific causes of low back pain (e.g., fracture, tumor, severe intervertebral disc degeneration, modic type(≥ II) [ 41 ], spinal stenosis, lumbarization, symptomatic scoliosis(Cobb > angle 25°) [ 42 ], spondylolisthesis, facet arthropathy [ 43 ], tuberculosis or rheumatic diseases) confirmed by orthopedic examination and imaging.② Patients with central nervous system disorders. ③ Patients with radicular symptoms (numbness or pain in lower limbs due to spinal nerve root compression [ 44 ]). ④ Patients with severe cardiovascular, cerebrovascular, hematologic, digestive, or psychiatric diseases. ⑤ Pregnant or lactating women. ⑥ Patients with severe impairment of heart, liver, or kidney function. ⑦ Patients with autoimmune diseases, allergic disorders, or acute/chronic infections. ⑧ Patients unwilling to participate in the trial. ⑨ Patients currently enrolled in other clinical trials. ⑩ Other conditions deemed unsuitable by the investigator. Since this was an exploratory study, we employed a per-protocol (PP) analysis to more clearly delineate the effects of exercise training targeting multifidus. From March 2023 to July 2023, a total of 60 patients were diagnosed with CNSLBP and approved to engaged in this trial and they were randomized to the EX group and the CON group. After the one-month intervention, 54 patients completed the trial, while six dropped out. Intervention. LSSE Two easy and convenient movements were used to strength and stretch paraspinal muscles, included Supine Straight Leg Raise and Hands to Feet Stretch. Supine Straight Leg Raise (Lumbar stabilization exercise, Fig. 2 ): Lie supine (on the back) with legs straight and together, arms resting on the abdomen. Inhale slowly while simultaneously lifting both legs upward. Key Points are reaching the highest position at the end of inhalation (e.g., legs at 45°~60° from the bed) and maintaining the position for approximately 5 s during exhalation. Without pausing, inhale steadily while lowering both legs back down. Start with 5 reps per day, progress to 10 reps with controlled movements. Fig. 2. Open in a new tab Supine straight leg raise (Lumbar stabilization exercise). a Lie supine (on the back) with legs straight and together, arms resting on the abdomen. b Integrate respiratory motion with positioning the legs at specific angles. Start with 5 reps per day, progress to 10 reps with controlled movements. The movements were demonstrated by Hongsheng Zhan Hands to Feet Stretch (Lumbar stretching exercise, Fig. 3 ): Sit on the bed/plinth with legs straightened. With bilateral upper extremities fully protracted, grasp the corresponding ankles, keeping the lower limbs adducted and knees in full extension. (For patients with limited flexibility, they can sit on the edge of a bed or high bench, with a lower bench/stool placed in front of you. Place both feet on the lower bench, keeping legs straight and together. Extend arms forward at shoulder height, palms facing down.) Maintain a straight spine and slightly lift the chin (‘forward-probing’ posture). Gently hinge forward from the hips, reaching your chin toward toes. Feel the stretch in your lower back, lumbosacral region, and hamstrings. Perform small, controlled back-and-forth movements (avoid bouncing). Keep breathing naturally (do not hold your breath). Twenty cycles per session and once daily. Fig. 3. Open in a new tab Hands to feet stretch (Lumbar stretching exercise). a Sit on the floor with legs straightened. b Grasp the corresponding ankles, keeping the lower limbs adducted and knees in full extension. c Maintain a straight spine and slightly lift the chin (‘forward-probing’ posture). Keep breathing naturally (do not hold your breath). Twenty cycles per session and once daily. The movements were demonstrated by Hongsheng Zhan Health education The health education program for patients comprised two integrated components: cognitive education and psychological support [ 45 ]. The cognitive education component provided personalized instruction on CNSLBP pathophysiology, risk factors, and evidence-based self-management strategies, while simultaneously addressing pain-related psychological distress. The psychological support component focused on correcting maladaptive beliefs (e.g., ‘back pain always indicates tissue damage’) and promoting active coping strategies through graded activity training. This dual approach aimed to enhance patients’ understanding of their condition while building psychological resilience for long-term recovery. Outcomes and follow-up An independent physician who was blinded to the intervention collected all the data at 0 week baseline and 4 weeks after intervention. During participant enrollment, we collected data on age, sex, height, body weight, and waist circumference and duration for subsequent analysis [ 46 ]. The primary outcome was VAS. VAS is a widely-used and well-validated instrument for assessing subjective pain intensity. A 10-cm straight line is drawn with the left end labeled “no pain” and the right end “worst pain imaginable” [ 47 ]. Patients marked their current pain level on the line. The distance (in cm) from the left end to the mark indicates pain intensity, with higher scores reflecting greater pain severity. Secondary outcomes included The Oswestry Disability Index (ODI), musculoskeletal ultrasound-measured muscle size and elasticity and MRI-measured bilateral multifidus muscle cross-sectional area (CSA) and gray-scale value (indicating fatty infiltration). ODI consists of ten items [ 48 ] assessing three major domains: pain (pain intensity and impact of pain on sleep), individual functions (lifting, sitting, standing and walking), and comprehensive personal functions (activities of daily living, sex life, social activities and traveling). We observed the CSA and elastic echo of bilateral L4/L5 and L5/S1 multifidus under musculoskeletal ultrasound. Use the HITACHI (Model: EZU-MT28-S1 L74M linear array probe) color Doppler ultrasound diagnostic apparatus to collect ultrasound images (Fig. 4 ). Besides we used the Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine Radiology Department’s Philips 15 high-field superconducting MRI (Coil: SYNERGY-SPINE) to collect MRI images of bilateral multifidus and erector spinae at L4/L5 and L5/S1 levels. All images were acquired using T2-weighted, spin-echo fat-saturated pulse sequences with pixel size 0.94 × 0.47 mm, matrix 255 × 512, and slice thickness 4 mm. We used ImageJ software (V1.8.0.112) to analyze the CSA and fatty infiltration of multifidus (Fig. 5 ). Fig. 4. Open in a new tab Musculoskeletal ultrasound assessments of multifidus. a multifidus cross-sectional area: C maximum width (mm), D maximum length (mm), A cross-sectional area (cm 2 ). b multifidus elasticity: select appropriate measurement points to quantify multifidus elasticity. The elastic echo value is derived from the average Shear wave velocity (SWV), calculated by summing the velocities of all selected points and dividing by the number of points. Vs shear wave velocity (m/s), depth measurement point depth (cm/mm) Fig. 5. Open in a new tab MRI assessments of multifidus and erector spinae. The yellow line ( a and b ) represents the coronal plane defined by the horizontal section. The red line a and b ) shows the MRI scan coverage a Acquisition of multifidus muscle at the L4/L5 vertebral level at the inferior endplate levels of the L4 vertebral body. b Acquisition of multifidus muscle at the L5/S1 vertebral level at the inferior endplate levels of the L4 vertebral body. c multifidus cross-sectional area and gray-scale values at the L4/L5 vertebral level: 1 right multifidus, 2 left multifidus, 3 right erector spinae, 4 right erector spinae. d multifidus cross-sectional area and gray-scale values at the L5/S1 vertebral level: 1 right multifidus, 2 left multifidus, 3 right erector spinae, 4 right erector spinae. label: file name, area: area (cm 2 ), mean: gray-scale value, max: maximum gray-scale value, min: minimum gray-scale value. MRI: magnetic resonance imaging, L4/L5 lumbar 4/lumbar 5 vertebral level, l5/s1 lumbar 5/sacral 1 vertebral level Statistical analysis SPSS 26.0 statistical software was used for all statistical analysis. A P value less than 0.05 was considered statistically significant. The continuous data are expressed as mean and standard deviation (SD), and the categorical data are expressed as frequency and percentages. The chi-square test was used to detect differences between binary variables. The Kolmogorov–Smirnov test was applied to the continuous data to determine if they followed a normal distribution. Baseline demographic characteristics and the mean improvement from baseline in each clinical outcome at follow-up visit were assessed for each patient. Student t test (for continuous data that were normally distributed), the Mann–Whitney U test (for continuous data that were not normally distributed), or generalized linear mixed model (GLMM) were applied for the study comparison. For outcomes analysis, GLMM was used for repeated measures. The changes from baseline measurements were modeled with GLMM. Differences in mean changes from baseline for each outcome at each time were compared between groups. The outcome model included fixed effects for treatment, time, and the interaction of trial group with time. Pearson correlation analysis was used to assess the correlation between MRI and musculoskeletal ultrasound of multifidus. Results A total of 60 participants (20 males and 40 females) with a mean age of 30.7 ± 9.8 years and a BMI of 21.5 ± 4.4 kg/m 2 were included in the study. The mean (SD) waist circumference was 69.7 (8.3) cm, duration of the current LBP episode was 24.6 (20.6) months, VAS score was 4.7 (1.3), and ODI score was 56% (12%). Thirty patients were included but three patients gave up and dropped up in the EX group. The CON group comprised 30 patients, but three of them were excluded due to loss of contact. A total of 54 patients were therefore analyzed. (Fig. 1 ) Independent samples t-tests and chi-square revealed that baseline clinical characteristics showed no significant differences, and all data were non-normally distributed. (Table 1 ) Table 1. Baseline characteristics of the participants characteristics CON ( n = 27) EX( n = 27) χ 2 /t P Gender n (%) 2.146 0.143 Male 6 (22.2) 11(40.7) Female 21(77.8) 16(59.3) Age(years) 29.44 ± 8.92 29.89 ± 9.87 − 0.174 0.863 BMI 21.54 ± 5.69 21.81 ± 3.22 − 0.213 0.832 waist (cm) 69.44 ± 9.33 69.30 ± 7.97 0.063 0.950 Duration (months) 26.63 ± 26.35 20.78 ± 13.39 1.029 0.310 Open in a new tab For measurement data conforming to normal distribution, data are presented as mean ± SD (standard deviation). For non-normally distributed data, data are expressed as median (first quartile, third quartile). CON the control group received health education alone, EX the intervention group received combined lumbar stabilization and stretching exercises and health education The Wilcoxon signed-rank test revealed that both groups showed significant reductions in VAS and ODI scores post-intervention, indicating that both exercise and health education interventions were effective for CNSLBP patients (All P < 0.001). The EX group reached the MCID in VAS, demonstrating that LSSE and health education provided clinically meaningful benefits. As determined by the Mann-Whitney U test, the EX group exhibited substantially greater improvements in both VAS and ODI scores compared to the CON group(All P < 0.05), highlighting the superior efficacy of the combined approach. Details are shown in Table 2 . Table 2. VAS/ODI scores: between-group comparison (pre-post intervention) Outcomes CON ( n = 27) EX ( n = 27) z P VAS Pre-intervention 5.0(4.0, 6.0) 5.0 (4.0, 5.0) -0.800 0.423 Post-intervention 4.0 (3.0, 4.0) a 2.0 (1.0, 2.0) a -4.506 < 0.001 ODI Pre-intervention 53%(46%, 59%) 59%(48%, 68%) -1.795 0.073 Post-intervention 35%(27%, 47%) a 17%(0%, 29%) a -3.535 < 0.001 Open in a new tab Data are expressed as median (first quartile, third quartile) a Denotes P < 0.05 versus pre-intervention values CON the control group received health education alone; EX the intervention group received combined lumbar stabilization and stretching exercises and health education; VAS, visual analog scale; ODI, oswestry disability index We performed paired-sample t-tests to evaluate the within-group differences in musculoskeletal ultrasound outcomes and used independent-sample t-tests to evaluate the between-group differences. The musculoskeletal ultrasound assessment results (Fig. 6 ) showed that compared with pre-intervention, the CON group exhibited a significant increase in the CSA of the multifidus muscle at bilateral L4/L5 (left side: t = − 3.394, P = 0.002, Cohen’s d = 0.466cm 2 , 95% Confidence Interval (CI) − 0.075, 1.007, right side: t = − 4.302, P < 0.001, Cohen’s d = 0.789cm 2 , 95% CI 0.235, 1.343;) and L5/S1 (left side: t = − 4.266, P < 0.001, Cohen’s d = 0.485cm 2 , 95% CI − 0.056, 1.026, right side: t = − 3.159, P = 0.004, Cohen’s d = 0.440cm 2 , 95% CI − 0.1, 0.98). And the EX group also showed positive outcomes in the CSA of the multifidus muscle at bilateral L4/L5(left side: t = − 5.132, P < 0.001, Cohen’s d = 0.733cm 2 , 95% CI 0.182, 1.284, right side: t = − 7.641, P < 0.001, Cohen’s d = 0.908cm 2 , 95% CI 0.348, 1.468) and L5/S1(left side: t = − 4.504, P < 0.001, Cohen’s d = 0.792cm 2 , 95% CI 0.238, 1.346, right side: t = − 5.399, P < 0.001, Cohen’s d = 0.650cm 2 , 95% CI 0.103, 1.197). And for muscle elasticity, a significant reduction was found only at the bilateral L4/5 level in the CON group post-intervention (left side: t = − 2.564, P = 0.016, Cohen’s d = − 0.637 m/s, 95% CI − 1.184, − 0.09, right side: t = − 2.346, P = 0.027, Cohen’s d = − 0.541 m/s, 95% CI − 1.084, 0.002). No other sites exhibited significant changes in elasticity and no significant within-group differences in CSA and elasticity (All P > 0.05). Detailed data are presented in Table 3 . Fig. 6. Open in a new tab Musculoskeletal ultrasound Outcomes of multifidus: between-group comparison (pre-post intervention). *indicates statistical significance. CON the control group received health education alone, EX the intervention group received combined lumbar stabilization and stretching exercises and health education, CSA cross-sectional area, L4/L5 Lumbar 4/Lumbar 5 vertebral level, L5/S1 Lumbar 5/Sacral 1 vertebral level. The figure was generated using GraphPad Prism Table 3. Musculoskeletal ultrasound outcomes of multifidus: between-group comparison (pre-post intervention) Ultrasound outcomes CON ( n = 27) EX ( n = 27) t P CSA (cm 2 ) Left L4/L5 Pre-intervention 4.99 ± 2.76 5.45 ± 2.10 − 0.690 0.493 Post-intervention 6.31 ± 2.90 a 6.88 ± 1.79 a − 0.874 0.386 Right L4/5 Pre-intervention 4.77 ± 1.85 5.23 ± 1.76 − 0.930 0.357 Post-intervention 6.15 ± 1.64 a 6.96 ± 2.04 a − 1.605 0.115 Left L5/S1 Pre-intervention 4.85 ± 2.03 4.88 ± 2.04 − 0.050 0.961 Post-intervention 5.84 ± 2.05 a 6.35 ± 1.65 a − 1.010 0.317 Right L5/S1 Pre-intervention 5.01 ± 2.17 4.85 ± 2.24 0.272 0.787 Post-intervention 5.93 ± 2.01 a 6.21 ± 1.93 a − 0.527 0.601 Elastic echo (m/s) Left L4/L5 Pre-intervention 1.99 ± 0.46 2.26 ± 0.57 − 1.887 0.065 Post-intervention 2.32 ± 0.57 a 2.21 ± 0.51 0.777 0.441 Right L4/5 Pre-intervention 2.08 ± 0.51 2.20 ± 0.44 − 0.930 0.357 Post-intervention 2.52 ± 1.03 a 2.15 ± 0.30 1.783 0.085 Left L5/S1 Pre-intervention 2.73 ± 0.36 2.26 ± 0.55 0.710 0.481 Post-intervention 2.20 ± 0.60 2.19 ± 0.39 0.030 0.976 Right L5/S1 Pre-intervention 2.11 ± 0.52 2.29 ± 0.54 − 1.263 0.212 Post-intervention 2.33 ± 0.81 2.17 ± 0.48 0.894 0.376 Open in a new tab Data are presented as mean ± SD a Denotes P < 0.05 versus pre-intervention values CON the control group received health education alone, EX the intervention group received combined lumbar stabilization and stretching exercises and health education, CSA cross-sectional area, L4/L5 Lumbar 4/Lumbar 5 vertebral level, L5/S1 Lumbar 5/Sacral 1 vertebral level, SD standard deviation MRI results (Figs. 7 ) further confirmed the changes in the CSA and fatty infiltration of the multifidus. Within-group differences in MRI outcomes were assessed using paired-sample t-tests, while between-group differences were evaluated using independent-sample t-tests. After intervention, the EX group demonstrated significant CSA increases at bilateral L4/L5 (left side: t = − 3.496, P = 0.002, Cohen’s d = 0.291cm 2 , 95% CI − 0.245, 0.827, right side: t = − 3.650, P = 0.001, Cohen’s d = 0.326cm 2 , 95% CI − 0.211, 0.863) and L5/S1 (left side: t = − 3.917, P = 0.001, Cohen’s d = 0.427 cm 2 , 95% CI − 0.112, 0.966, right side: t = − 5.046, P < 0.001, Cohen’s d = 0.459 cm 2 , 95% CI − 0.081, 0.999), along with reduced grayscale values at bilateral L5/S1 level (left side: t = 3.227, P = 0.003, Cohen’s d = − 0.705, 95% CI − 1.255, − 0.155; right side: t = 3.398, P = 0.002, Cohen’s d = − 0.778, 95% CI − 1.331,− 0.225), indicating decreased fatty infiltration. In contrast, the CON group showed no significant improvement at any outcomes. Intergroup analysis revealed that the EX group had significantly greater CSA growth at right L5/S1 compared to the Con group (t = − 2.489, P < 0.05, Cohen’s d = 0.676 cm 2 , 95% CI 0.128, 1.224). Detailed data are presented in Table 4 . Fig. 7. Open in a new tab MRI Outcomes of multifidus: between-group comparison (pre-post intervention). *Indicates statistical significance. MRI magnetic resonance imaging, CON the control group received health education alone, EX the intervention group received combined lumbar stabilization and stretching exercises and health education, CSA cross-sectional area, L4/L5 Lumbar 4/Lumbar 5 vertebral level, L5/S1 Lumbar 5/Sacral 1 vertebral level. The figure was generated using GraphPad prism Table 4. MRI outcomes of multifidus: between-group comparison (pre-post intervention) MRI outcomes CON ( n = 27) EX ( n = 27) t P CSA (cm 2 ) Left L4/L5 Pre-intervention 6.31 ± 1.45 6.99 ± 2.54 − 1.220 0.229 Post-intervention 6.65 ± 1.68 7.74 ± 2.61 a − 1.821 0.074 Right L4/5 Pre-intervention 6.61 ± 1.62 7.19 ± 2.40 − 1.044 0.301 Post-intervention 6.95 ± 1.91 8.05 ± 2.86 a − 1.664 0.102 Left L5/S1 Pre-intervention 7.44 ± 1.54 8.00 ± 2.44 − 1.013 0.316 Post-intervention 8.27 ± 2.99 9.15 ± 2.92 a − 1.102 0.275 Right L5/S1 Pre-intervention 7.63 ± 1.65 7.75 ± 2.41 − 0.223 0.825 Post-intervention 7.39 ± 1.70 8.94 ± 2.76 a − 2.489 0.016 Gray-scale value Left L4/L5 Pre-intervention 31.48 ± 9.05 30.53 ± 6.52 0.445 0.658 Post-intervention 31.38 ± 9.15 28.06 ± 5.09 1.648 0.107 Right L4/5 Pre-intervention 33.91 ± 9.01 33.00 ± 7.85 0.399 0.692 Post-intervention 32.53 ± 8.13 30.62 ± 5.98 0.984 0.330 Left L5/S1 Pre-intervention 28.44 ± 6.82 30.06 ± 5.64 − 0.950 0.347 Post-intervention 27.95 ± 7.92 26.50 ± 4.38 a 0.832 0.411 Right L5/S1 Pre-intervention 30.55 ± 6.40 31.28 ± 6.28 − 0.424 0.673 Post-intervention 28.74 ± 6.66 26.81 ± 5.16 a 1.195 0.238 Open in a new tab Data are presented as mean ± SD a Denotes P < 0.05 versus pre-intervention values MRI, magnetic resonance imaging; CON the control group received health education alone; EX the intervention group received combined lumbar stabilization and stretching exercises and health education; CSA, cross-sectional area; L4/L5 Lumbar 4/Lumbar 5 vertebral level; L5/S1 Lumbar 5/Sacral 1 vertebral level; SD, standard deviation MRI further revealed changes in the erector spinae muscles (Fig. 8 ; Table 5 ). Independent samples t-tests showed no statistically significant differences in the CSA and grayscale values of the erector spinae muscles between two groups. However, paired samples t-tests indicated that, within the EX group, the CSA of the erector spinae increased at the bilateral L4/5 level (left side: r = − 0.17, P < 0.05, Cohen’s d =  0.34 cm 2 , 95% CI − 0.202, 0.872; right side: r = − 0.16, P < 0.05, Cohen’s d = 0.33 cm 2 , 95% CI − 0.211, 0.863) and L5/S1 level (left side: r = − 0.13, P < 0.05, Cohen’s d = 0.26 cm 2 , 95% CI − 0.272, 0.8; right side: r = − 0.19, P < 0.05, Cohen’s d = 0.38 cm 2 , 95% CI − 0.163, 0.913) after the intervention, while the gray-scale values decreased at the bilateral L5/S1 level (left side: r = 0.25, P < 0.05, Cohen’s d = − 0.51, 95% CI − 1.052, 0.032,; right side: r = 0.21, P < 0.05, Cohen’s d = − 0.42, 95% CI − 0.957, 0.121,). In contrast, no significant differences were observed within the CON group after the intervention. Fig. 8. Open in a new tab MRI Outcomes of erector spinae: between-group comparison (pre-post intervention). *Indicates statistical significance. MRI magnetic resonance imaging, CON the control group received health education alone, EX the intervention group received combined lumbar stabilization and stretching exercises and health education, CSA cross-sectional area, L4/L5 Lumbar 4/Lumbar 5 vertebral level, L5/S1 Lumbar 5/Sacral 1 vertebral level. The figure was generated using GraphPad prism Table 5. MRI outcomes of erector spinae: between-group comparison (pre-post intervention) MRI outcomes CON ( n = 27) EX( n = 27) t P CSA (cm 2 ) Left L4/L5 Pre-intervention 12.81 ± 2.70 12.68 ± 3.36 0.160 0.873 Post-intervention 13.17 ± 2.79 13.92 ± 4.01 a −0.795 0.430 Right L4/5 Pre-intervention 12.75 ± 2.29 12.76 ± 3.86 − 0.018 0.986 Post-intervention 12.90 ± 2.73 14.13 ± 4.53 a − 1.202 0.235 Left L5/S1 Pre-intervention 8.25 ± 2.96 9.11 ± 3.59 − 0.962 0.316 Post-intervention 8.58 ± 2.65 10.03 ± 3.38 a − 1.756 0.085 Right L5/S1 Pre-intervention 8.30 ± 2.87 9.08 ± 3.40 −  0.911 0.366 Post-intervention 8.78 ± 2.82 10.40 ± 3.64 a − 1.825 0.074 Gray-scale value Left L4/L5 Pre-intervention 36.36 ± 8.49 35.64 ± 8.39 0.311 0.757 Post-intervention 34.95 ± 9.10 32.96 ± 8.03 0.849 0.400 Right L4/5 Pre-intervention 36.80 ± 7.33 36.79 ± 7.61 0.009 0.993 Post-intervention 36.30 ± 8.18 34.47 ± 7.48 0.857 0.395 Left L5/S1 Pre-intervention 36.80 ± 10.48 39.26 ± 10.03 − 0.881 0.382 Post-intervention 35.56 ± 12.37 34.18 ± 9.91 a 0.453 0.652 Right L5/S1 Pre-intervention 39.26 ± 12.34 39.94 ± 10.71 − 0.216 0.83 Post-intervention 38.68 ± 10.82 35.83 ± 8.89 a 1.059 0.294 Open in a new tab Data are presented as mean ± SD a Denotes P < 0.05 versus pre-intervention values MRI magnetic resonance imaging, CON the control group received health education alone, EX the intervention group received combined lumbar stabilization and stretching exercises and health education, CSA cross-sectional area, L4/L5 Lumbar 4/Lumbar 5 vertebral level, L5/S1 Lumbar 5/Sacral 1 vertebral level, SD standard deviation Pearson correlation analysis (Table 6 ) revealed significant correlation between CSA of multifidus measured by MRI and musculoskeletal ultrasound at left L4/5 ( r = 0.315, P = 0.02). However, no significant positive correlations were observed at other levels (All P > 0.05). Table 6. Correlation analysis between CSA of multifidus measured by MRI and musculoskeletal ultrasound Left L4/L5 Right L4/L5 Left L5/S1 Right L5/S1 r 0.315 0.198 0.260 0.156 P 0.02 0.152 0.058 0.261 Open in a new tab MRI, magnetic resonance imaging; CSA, cross-sectional area; L4/L5 Lumbar 4/Lumbar 5 vertebral level, L5/S1 Lumbar 5/Sacral 1 vertebral level Discussion As the first study to investigate the efficacy of LSSE on lumbar paraspinal muscles characteristics in CNSLBP, our study found that this specific intervention significantly alleviates pain and improves functional capacity in patients with CNSLBP. The EX group demonstrated significantly greater improvement in both pain relief and functional scores compared to the control group and the reduction in VAS in the EX group met the MCID. The health education control group also showed promising outcomes at VAS and ODI, suggesting that combining patient education with LSSE may represent an optimal treatment for CNSLBP management. We also assessed the effect of these exercises on multifidus and erector spinae muscles in CNSLBP by evaluating their morphological and functional characteristics through CSA, gray-scale values, and elastic ultrasound imaging. Notably, the one-month therapeutic exercise regimen led to measurable morphological improvements in multifidus and erector spinae, including increased CSA and reduced fatty infiltration, especially located in the L5/S1 level. Our study demonstrated significant positive correlations between musculoskeletal ultrasound and MRI measurements of multifidus CSA only at left L4/L5 level and the results support the preference for MRI over musculoskeletal ultrasound when precise morphological assessment of the multifidus is required. CNSLBP is associated with multiple mechanisms in its development and progression, including specific structural and biological factors, genetic factors, excessive static/dynamic loading, psychological factors, behavioral/environmental factors, and expectations about pain [ 48 , 49 ]. Among these, the specificity and diversity of musculoskeletal factors are considered key to the development of LBP [ 45 ]. Current research on spinal musculoskeletal factors primarily focuses on degenerative discopathy [ 50 ], connective tissue pathologies [ 51 ], facet joints osteoarthritis [ 52 ], paraspinal muscles, and peripheral nerves [ 49 ]. The erector spinae and multifidus are both crucial paraspinal muscles to lumbar movement and stabilization. In the EX group, both muscles showed notable increases in CSA and reduction in fatty infiltration compared to pre-intervention levels, whereas the CON group exhibited no significant changes. These results confirm the efficacy of LSSE for enhancing both muscles. The erector spinae are the largest lumbar muscle and their adaptation to lumbar motion demonstrates particular relevance to LBP rehabilitation. Emerging evidence also suggests a bidirectional relationship between degenerative changes in multifidus atrophy and LBP progression [ 53 ]. Furthermore, the CSA, fatty infiltration, and elasticity of paraspinal muscles serve as key indicators for assessing its functional status [ 54 , 55 ]. Consistent with these previous findings, our results demonstrated a positive association between improvements in paraspinal muscles characteristics and clinical recovery in CNSLBP patients. Although the precise mechanistic pathways remain incompletely understood [ 56 ], recent investigations have associated muscles degeneration with fatty infiltration, fibrosis, and atrophy [ 53 , 57 ] .Fatty degeneration of muscles is characterized by intracellular lipid infiltration, not extracellular fat deposition [ 58 ] and the remodeling process of fibrosis is concurrently accompanied by reductions in CSA with a predominant decrease in type I (slow-twitch oxidative) fibers and a relative increase in type IIX (fast-twitch glycolytic) fiber proportion [ 59 ]. Additionally, resulting from the loss of contractile proteins, muscle atrophy manifests as decreased CSA of individual muscle fibers and the entire muscle [ 60 ]. Exercise therapy has been widely recognized as an important intervention for CNSLBP [ 61 , 62 ]. It primarily achieves pain relief and quality-of-life enhancement [ 17 ] by remodeling muscles and regulating psychological states [ 63 ]. Recent studies demonstrate a positive correlation between exercise adherence and clinical improvement in CNSLBP patients [ 64 ]. And compared to traditional whole-body exercises like Pilates [ 65 ], LSSE targets training for lumbosacral core muscles demonstrates superior clinical outcomes for CNSLBP [ 66 ]. For instance, pelvic clock exercises can promote the recovery of lumbosacral muscles specifically and it effectively improve pain symptoms and lumbopelvic proprioception in middle-aged women with CNSLBP [ 67 ]. And motor control exercise activates deep muscles and shows clear clinical benefits for chronic LBP [ 68 ]. Consistent with these researches, our study focuses on lumbar muscles’ stabilization and flexibility, confirming a significant positive correlation between paraspinal muscle functional improvements and clinical symptom relief of CNSLBP [ 68 ]. Notably, our study revealed significantly more pronounced bilateral muscular changes of at the L5/S1 segment in CSA and gray-scale values. This may be related to the location and function. The multifidus at this level exhibit greater volume compared to superior lumbar segments [ 69 ]. This structural advantage enhances its sensitivity to exercise-induced adaptations, resulting in more rapid hypertrophy and functional improvement in response to exercise training [ 70 ]. Moreover, spinal loads and net moments increased caudally, reaching their maximum at the lowermost L5/S1 level [ 71 ]. The increased mechanical demand drives more detectable morphological and functional changes in this critical transitional zone during exercises, especially flexion-extension motion [ 71 ]. Thus, the paraspinal muscles demonstrate a great improvement at this level. Our study observed statistically significant between-group differences in the multifidus muscle solely at the right L5/S1 level, with no significant differences detected at other levels of the multifidus and erector spinae. This phenomenon may be attributed to several factors. First, the limited sample size may prevent the detection of subtle yet existing differences due to the reduced statistical power [ 72 ]. Second, the intervention duration may have been insufficient to induce structural adaptations in these muscles because morphological and histological changes typically require prolonged periods to manifest [ 73 ]. To enhance patient compliance, we employed an intervention consisting of simple movements, which may produce only modest effects on paraspinal muscles. Consequently, a longer intervention period might be necessary to elicit more detectable between-group differences. This inference aligns with previous literature; for instance, study has shown that fatty infiltration of the multifidus observed during the pain relief phase of low back pain [ 74 ]. And the short-term active passive exercise does not seem to increase trunk muscle size [ 75 ]. It indicates that such structural alterations represent a slow pathophysiological process, whose reversal similarly requires sustained long-term intervention [ 75 ]. Third, due to equipment limitations, this study focused primarily on the paraspinal muscles in the lower back. The multifidus acts as a key segmental stabilizer of the lumbar spine. Existing study indicates that even in asymptomatic individuals, structural changes such as fat infiltration are commonly observed in the multifidus at the lower lumbar levels. In contrast, alterations in the erector spinae, particularly at the upper lumbar levels, appear to be more specifically associated with LBP [ 76 ]. This aligns with the biomechanical models of lumbar back muscles that the erector spinae contribute a substantial proportion of the lumbar extensor moment [ 77 ]. Therefore, the assessment of the upper lumbar muscles, especially the erector spinae, will be incorporated into future investigations of lumbar spine pathophysiology. Unlike the other outcomes, the muscle elasticity values in this study did not demonstrate significant clinical changes, which we speculate may be associated with muscular tension status. It’s confirmed that the sensitivity, specificity, and accuracy of elastic ultrasound in detecting changes in muscle properties differ between relaxed and tense states [ 78 ]. We also found that measurements were more accurate in tense states and further research would focus on elastic echo measurements in tense states. Moreover, the multifidus muscle measured by musculoskeletal ultrasound showed a statistically significant correlation with MRI only at the right L5/S1 level, and ultrasound was also able to detect post-exercise changes in the multifidus. Therefore, musculoskeletal ultrasound, as a non-invasive, cost-effective, and convenient imaging tool [ 79 ], can be used for preliminary assessment of deep muscles like the multifidus. Although, for precise measurement, MRI remains the recommended modality. Besides, health education targets comprehensive lifestyle modifications and has been confirmed to provide significant long-term benefits for CNSLBP management [ 45 , 62 ]. This aligns with the results of this trial, suggesting that health education should be the first and basic step in treating CNSLBP. Health education helps patients develop a correct understanding of CNSLBP and maintain a positive attitude toward treatment [ 80 ]. However, a study shows the addition of health education to structured physiotherapy did not yield significant further reductions in pain or disability [ 81 ]. This positions health education not as a direct alternative to active therapy, but as a foundational component that supports long-term self-management within a comprehensive treatment plan. All in all, the strong association between paraspinal muscles and lumbar stability has long supported the hypothesis that paraspinal muscles degeneration contributes to chronic lumbar dysfunction and pain [ 27 , 82 , 83 ]. Our study not only corroborates this hypothesis but also demonstrates that LSSE significantly improves both pain and functional outcomes in patients with CNSLBP. Thereby it provides mechanistic and clinical validation for this pathological relationship. There are several limitations in our study. Due to time constraints, the duration of intervention in this study was relatively short and no follow-up was conducted after the intervention. Therefore, the long-term efficacy of interventions (such as beyond six months) was not assessed [ 84 ]. This could potentially account for the lack of significant between-group differences. Besides, due to the lack of standardized guidelines for health education on LBP [ 6 ], this study primarily provided individualized recommendations based on avoiding risk factors related to LBP and fostering a positive attitude toward the condition; however, it lacked a unified and widely accepted guidance framework. Further research could focus on the long-term effects and refine the standards for health education. Last but not least, growing evidence highlights the significance of erector spinae at upper lumbar levels and gluteal muscles in LBP [ 76 , 85 ]. A further limitation in this study is the absence of assessment for the upper lumbar paraspinal muscles and gluteal musculature. The study’s focus on the lower lumbar region precluded evaluation of these structures. Future investigations should encompass the entire lumbopelvic complex for a more integrated understanding of CNSLBP. In addition, key lumbopelvic bony parameters, including lumbar lordosis and pelvic incidence, should be measured at the time of participant enrollment. Conclusion This study provides evidence that a one-month LSSE program is an effective intervention for CNSLBP, leading to significantly greater reductions in pain and disability compared to health education alone. These clinical improvements were accompanied by favorable structural changes within the intervention group, including increased CSA and reduced fatty infiltration of the paraspinal muscles at the lower lumbar spine. Importantly, between-group analysis confirmed a significant increase specifically in the CSA of the right L5/S1 multifidus. This finding points to targeted muscle hypertrophy as a potential mechanism underlying the benefits of LSSE and warrants further investigation to elucidate the comprehensive biomechanical pathways involved. Supplementary Information Below is the link to the electronic supplementary material. Supplementary Material 1. (368.6KB, pdf) Acknowledgements We sincerely thank all participants involved in this study. We also extend our gratitude to Jianguo Sheng, Yuhao Zhao, Haiya Ge, Jiehang Lu, Zhengming Wang, Yuyun Wu and Guoqing Du for their valuable support in patient recruitment and technical support. We are especially grateful to Yihan Qian for her invaluable assistance in refining the figures. Abbreviations CNSLBP Chronic nonspecific low back pain LSSE Lumbar stabilization and stretching exercises CON The control group EX The intervention group VAS Visual analog scale ODI Oswestry disability index CSA Cross sectional area LBP Low back pain CONSORT Consolidated standards of reporting trials MCID Minimum clinically important difference PP Per protocol SD Standard deviation GLMM Generalized linear mixed model CI Confidence interval Author contributions The study was conceived and designed by Hongsheng Zhan and Xiang Wang, who also supervised the project and critically revised the manuscript. Xiaoyu Guo and Wuwei Song developed the exercise protocols, conducted outcome assessments, collected data, performed statistical analysis, and wrote the first draft. Lulu Zhao was responsible for patient recruitment and outcome assessment. Chen Wei managed data curation and prepared figures. All authors reviewed, revised, and approved the final manuscript for submission. Funding This study was supported by the National Natural Science Foundation of China (82374481), Shanghai clinical specialty traditional Chinese medicine orthopaedic traumatology (shslczdzk03901), Clinical study of traditional Chinese manipulation in the treatment of the Frozen Shoulder Syndrome (22Y21920200). Data availability The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Declarations Ethics approval The Ethics Committee of Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine approved the study (2022-1185-122-01), and informed consent was obtained from all participants. The trial was conducted following the Declaration of Helsinki. Consent for publication Consent for publication of figures was obtained from Hongsheng Zhan. Competing interests The authors declare no competing interests. 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[ DOI ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials Supplementary Material 1. (368.6KB, pdf) Data Availability Statement The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. 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