Effects of a stability ball exercise programme on low back pain

and daily life interference during pregnancy

Chiu-Fang Yan, MS, CNM, RN (Clinical Instructor)
a
, Ya-Chi Hung, MS
(Instructor, PhD student)
b,c
, Meei-Ling Gau, PhD, CNM, RN, IBCLC (Professor)
d,n,1
,
Kuan-Chia Lin, PhD (Professor, Statistician)
e,1
a
Department of Nursing, Chang-Gung University of Science and Technology, Taoyuan, Taiwan
b
Department of Exercise and Health Science, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
c
Department of Physical Therapy and Assistive Technology, National Yang-Ming University, Taipei, Taiwan
d
Graduate Institute of Nurse-Midwifery, National Taipei University of Nursing and Health Sciences, No. 365, Ming-Te Road 112, Taipei, Taiwan
e
Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
a r t i c l e i n f o
Article history:
Received 19 October 2012
Received in revised form
26 April 2013
Accepted 30 April 2013
Keywords:
Pregnancy
Low back pain
Stability ball exercise
Daily life interference
a b s t r a c t
Background: most pregnant women experience back pain during pregnancy, a serious issue that
negatively impacts life quality during pregnancy. Research into an exercise intervention programme
targeting low back pain and daily life interference is lacking.
Objective: this study evaluates how a stability ball exercise programme inuences low back pain and
daily life interference across the second and third pregnancy trimester.
Methods: the study was non-randomised and controlled, examining a target population of low-risk
pregnancy women between 20 and 22 weeks of gestation located in a regional hospital in northern
Taiwan. All participants had at least minimal low back pain, no prior history of chronic low back pain
before pregnancy, and no indications of preterm labour. In total, 89 individuals participated: 45 in the
control group and 44 in the experimental group (who attended an antenatal stability ball exercise
programme). This programme lasted 12 weeks, composed of at least three sessions per week. Fitness
workouts lasted from 25 to 30 minutes. The women completed their basic personal information, the Brief
Pain InventoryShort Form, and the Family Exercise Support Attitude Questionnaire.
Results: after adjusting for demographic data and antenatal exercise status by propensity scores,
experimental-group women who participated in the antenatal stability ball exercise programme
reported signicantly less low back pain and daily life interferences than the control group at 36 weeks
of gestation.
Discussion: the inclusion of stability ball exercises during pregnancy may reduce pregnancy low back
pain and boost daily life functions. This stability ball exercise programme provides health-care
professionals with an evidence-based intervention.
& 2013 Elsevier Ltd. All rights reserved.
Introduction
Pregnancy-related low back pain (PR-LBP) is one of the most
commonly reported complaints among pregnant women, varying
from 50% to 70% based on previous studies (Forrester, 2003;
Vermani et al., 2010). In Taiwan, PR-LBP is especially prevalent
(75%) (Chang et al., 2011). More than 80% of pregnant women with
LBP experience daily discomfort, and consequently struggle with
housework, childbearing, and job performance (Wang et al., 2004;
Mogren, 2007). In about 30% of women with LBP during preg-
nancy, this pain adversely impacts life quality, requiring frequent
periods of bed rest, and leading to work absences (Sydsjo et al.,
1998; Mogren, 2007).
The most common causes of PR-LBP are hormonal, mechanical,
and circulation changes, or a combination of the three (Wang et al.,
2004; Ho et al., 2009a; Vermani et al., 2010). Hormonal changes
cause a laxity within the joints and ligaments in the back and
pelvis (Forrester, 2003; Vermani et al., 2010). Meanwhile, postural
alterations in balance occur from an increase in uterine volume
(Wang et al., 2004; Ho et al., 2009a). Also signicant to LBP are the
effects of fetus weight on the lumbosacral nerve roots and the
reduction in the blood ow due to compression of the great
vessels by the gravid uterus (Forrester, 2003; Wang et al., 2004;
Vermani et al., 2010).
Ho et al. (2009a, 2009b) summarised previous studies and advised
on current low back pain relief strategies including brief rest, low-
healed shoes, avoiding certain physical activities, heat application, pain
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http://dx.doi.org/10.1016/j.midw.2013.04.011
n
Corresponding author.
E-mail addresses: meeiling@ntunhs.edu.tw (M.-L. Gau),
kuanchia@ntunhs.edu.tw (K.-C. Lin).
1
Contributed equally to this paper.
Please cite this article as: Yan, C.-F., et al., Effects of a stability ball exercise programme on low back pain and daily life interference
during pregnancy. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.04.011i
Midwifery ()
medication, exercises (core muscle strength, water gymnastics, yoga),
education and ergonomic advice, acupuncture, massage, relaxation,
and chiropractise treatment. Amongst these preventive and therapeu-
tic interventions, exercises may be the most benecial both to the
mother as well as the fetus. Regarding maternal health, benets
include the prevention and treatment of gestational diabetes, the
prevention of pre-eclampsia, a decrease in excessive weight gain, a
decrease in common physical discomforts associated with pregnancy
such as backaches, constipation, bloating, and fatigue (Lokey et al.,
1991; American College of Obstetricians and Gynecologists (ACOG),
2003; Dempsey et al., 2005). In addition, exercise during pregnancy
has psychological benets, such as improved self-esteem, mental
stability, and decreases in depression symptoms (American College
of Obstetricians and Gynecologists (ACOG), 2003; Poudevigne and
OConnor, 2005).
Concerning the fetus health, Juhl et al. (2008) indicated that
exercise during pregnancy actually reduces the risk of complica-
tions. They analysed data of over 85,000 births in Denmark to
examine the relation between physical exercise during pregnancy
and the risk of preterm birth. Results indicated a reduced risk of
preterm births among the almost 40% of women who engaged in
some kind of exercise during pregnancy compared to non-
exercisers (hazard ratio0.82, 95% condence interval: 0.76, 0.88).
According to the centre of gravity theory, which posits that
during pregnancy the centre of gravity moves forward and thus
requiring strong core muscles to maintain the stability of lumbar
spine and the pelvic girdle (Borg-Stein and Dugan, 2007). Previous
studies have shown that strengthening the body's core muscles
during pregnancy reduces the chance of back injury (Petrofsky
et al., 2005, 2008) and diminishes back pain (Dumas et al., 1995).
Because these muscle groups stabilise the trunk, core strength
enhances the body's balance. Traditionally, this has been accom-
plished through relatively stable benches and oors or, more
recently, via the incorporation of more unstable platforms, e.g.
Swiss Balls, which are effective due to their inherent instability.
Unstable training environments reportedly enhance training
effects through increased activation of stabilisers and core mus-
cles, in turn improving neuromuscular co-ordination. Vera-Garcia
et al. (2000) compared the abdominal muscle response during
curl-ups on both stable and labile surfaces in eight men with good
health and no history of LBP. Performing curl-ups on labile
surfaces was shown to have much higher amplitude of abdominal
muscle activity than stable bench exercises. The authors suggest a
much higher demand on the motor control system, which may be
desirable for LBP treatment. Previous studies also conrm evi-
dence of the role of stabilisation exercises in LBP. Marshall and
Murphy (2006) evaluated 20 patients with LBP over the course of a
12-week rehabilitation programme using the Swiss ball. They
found this modality of exercise may successfully improve the
functional capacity of patients with chronic non-specic LBP,
attributing the reduction in disability to the improvement of the
exion relaxation response of the erector spinae. Shen et al. (2009)
investigated the biomechanical impact of Swiss ball training on
the stability of lumbar vertebra in patients with intervertebral disc
herniation. After four weeks of Swiss ball training, researchers
assessed pain, abdominal and back muscle strength, with lumbar
traction compared to a control group that only utilised lumbar
traction. Among the experiment group, they found that abdominal
and back strength increased signicantly and pain level decreased
signicantly, concluding that the stability of the lumbar vertebra
increased signicantly with the use of Swiss ball and lumbar
traction exercises.
Previous studies have suggested that many factors may
decrease muscle strength, which accounts for LBP. These factors
included age (Owino et al., 2001), parity (Mogren and Pohjanen,
2005; Albert et al., 2006), body mass index (Mogren and Pohjanen,
2005), occupational status (Mogren and Pohjanen, 2005; Chang
et al., 2012) and habitual exercise (Ostgaard et al., 1994). Educa-
tional level (Chang et al., 2012) and social support (van Dijk et al.,
2006) were associated with pain and pain interference. These
ndings may be due to the possibility that people with lower
educational levels may have less self-care knowledge. Moreover,
those with higher social support may have access to a higher level
of personal assistance that reduces the need to perform daily
activities, in turn reducing their pain interference perceptions
(Chang et al., 2012). Perceived social support has also been
described as a signicant factor associated with exercise behaviour
(Resnick et al., 2002). Social support related to exercise behaviour
may be instrumental, informational, emotional, or appraisal. These
different types of support suggest that social inuences may have
a direct effect on exercise behaviour (Albright et al., 2005;
Thornton et al., 2006).
In sum, factors previously identied in the literature as asso-
ciated with LBP and exercise behaviour include: age, parity,
education, body mass index, occupational status, habitual exercise,
and social support. Using this research as a foundation to adjust
for confounding variables, this study evaluated how stability ball
exercise programme inuence low back pain and daily life inter-
ference across the second and third pregnancy trimester.
Methods
Design
This was a non-randomised controlled experimental study,
with data collected from January to December 2010. In reverence
to Chinese culture and tradition, some participants may have been
discouraged from exercising during pregnancy due to concerns of
interfering with Tai-Shen or Tai-Qi (spirit of fetus), an undesir-
able outcome that is believed to lead to spontaneous abortion or
preterm labour (Sung, 1996). For this reason, participants were
permitted to select their preferred group.
Study participants
Female inclusion criteria were as follows: (1) primigravida at
2224 weeks of gestation, (2) age 18 years, (3) no major obstetric
nor medical pregnancy complications based on antenatal charting,
(4) singleton pregnancy, (5) at least minimal LBP present, (6) nor-
mal extremities and capable of regular physical activity, and
(7) able to listen, speak, read and write in Chinese. Participants
with chronic LBP associated with sciatica before pregnancy, or any
signs of preterm labour were excluded.
A statistical power analysis was used to calculate the required
sample size; 0.05, power0.8 and effective size0.3 were
assumed. On the basis of GnPower (Germany; version 3.1.1, Fual
et al., 2007), a one-tailed test and an effect size value detected the
changes in pain level between groups. The sample size was
determined to be optimal at 41 participants per group. The authors
permitted an attrition rate of 20%. The suggested attrition rate was
estimated from previous longitudinal studies ranging from 6.8 to
27.4% (To and Wong, 2003; Mogren, 2007; Chang, 2011).
Initially, the principle investigator (PI) contacted 375 pregnant
women, of which 102 participants were recruited: 51 in the
experimental group and 51 in the control (Fig. 1). However, some
participants (n13) withdrewfor the following reasons: (1) unable
to be contacted (n3), (2) preterm labour (n5), (3) bleeding
(n1), and (4) frequent uterine contractions (n4). Six partici-
pants from the experimental group and seven participants from
the control group were removed from the original sample number,
C.-F. Yan et al. / Midwifery () 2
Please cite this article as: Yan, C.-F., et al., Effects of a stability ball exercise programme on low back pain and daily life interference
during pregnancy. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.04.011i
a 12.8% loss. The nal study group included 45 participants in the
experimental group and 44 participants in the control group.
Setting
Women were recruited from the antenatal educational classes
in a large urban hospital in northern Taiwan. At this hospital, all
women received standard obstetric care, including 1012 regular
physical check-ups and one-to-one antenatal care. Depending on
the gestation level of the participant woman, nursing staff offered
one-to-one antenatal care during their antenatal check-ups,
including pregnancy-related discomfort management, weight con-
trol, nutrition, exercise, breast-feeding skills, childbirth prepara-
tion, and parenting skills,. The hospital also offered four-sessions
of antenatal educational classes monthly. The topics were repeated
monthly and taught by four antenatal educators, covering topics
related to healthy behaviour, signs and stages of labour, comfort
measures during labour, medical interventions, postpartum recov-
ery, breast feeding and baby care. The programmes are open to
pregnant women and their support people.
Antenatal stability ball exercises programme
The antenatal stability ball programmes comprised a one-page
exercise protocol and 32-minute videotape programme. The pro-
gramme was designed by a tness specialist who held a Masters
degree in exercise science and was a certied tness and aerobics
instructor. This individual spent 15 years teaching stability ball
exercises, and had worked as an instructor at a northern Taiwa-
nese university. In total, the training programme featured 14
stabilisation exercises that focused on transversely-oriented
abdominals, the lumbar multidus, and pelvic oor muscles
(Table 1). Prior to the study, the primary investigator (PI) took a
tness course and seminars related to stability exercises. The PI
practised the exercises under the supervision of the exercise
programme designer.
We provided three different ball sizes to the participants, 55,
65, and 75 cm in diameter. The appropriate size of ball is
determined by the participant's height (Carriere, 1998; Perez,
2000). In order to maintain balance exercises, the woman has
the mobility to maintain a neutral spine easily when sitting with
hips and knees at an angle of approximately 901 (Carriere, 1998).
The ball must be rmly inated, and keep sharp objects away from
the ball. All balls have passed the security check, which can bear at
least 200 kg weight.
In a formal study, the PI provided individual guidance twice a
week. All members of the experimental group were requested to
attend stability ball exercise class at least once a week and practise
at home 2530 minutes two times a week for a period of 12 weeks.
To ensure research protocol compliance, a weekly training diary
was maintained during the training period. The PI also personally
called all participants to ensure their active involvement in
the study.
Measurements
The following demographic information was collected: age,
education, occupation, height, weight (pre-pregnancy weight,
gestational body weight, and body weight gains), pre-pregnancy
body mass index (BMI), and pre-pregnancy exercise behaviour.
The Brief Pain InventoryShort Form Taiwanese Version
Pregnancy-related low back pain was measured by the Brief
Pain InventoryShort Form Taiwanese Version (BPI-T) (Ger et al.,
1999). BPI-T is a patient-based assessment tool comprising two
parts. The rst consists of 4 items: pain location, pain severity,
analgesics used, and pain relief. It evaluates worst, average, and
current pain intensity on a scale of 010, with no pain and worst
possible pain serving as descriptive anchors. For the second, the
patient is asked seven categories concerning pain interference in
daily life, including: general activity, mood, walking ability, normal
work, relations with others, sleep, and enjoyment of life. These
categories are scored on a scale of 010 (0no interference and
10complete interference). The questionnaire's reliability and
validity was conrmed in patients with rheumatoid arthritis,
chronic low back pain, and HIV/AIDS (Cleeland and Ryan, 1994;
Harris et al., 2006; Leppert and Majkowicz, 2010). Studies into the
psychometric properties of the BPI-T have indicated that the
instrument is relatively independent of cultural and linguistic bias
(Cleeland and Ryan, 1994; Harris et al., 2006; Leppert and
Majkowicz, 2010). The Taiwan version also exhibits strong psycho-
metric properties, including excellent internal consistent internal
consistency, testretest reliability, and construct validity (Ger et al.,
1999). In this study, Cronbach's alpha coefcient for the pain
severity and pain interference during the four data collecting
times ranged from 0.86 to 0.91.
The Family Exercise Support Attitude Questionnaire
After reviewing the literature, investigators developed the
Family Exercise Support Attitude Questionnaire (FESAQ)
(Ho, 2004; Dishman et al., 2010) and in consultation with four
experts on physical therapy, recreational sports and health promo-
tion, and obstetrics nursing. The value of CVI was 1.00. The
questionnaire included three dimensions of exercise support:
informational, emotional, and instrumental support from family
members. Each item was scored on a ve-point scale. In total, this
questionnaire included seven items where total scores ranged
from 7 to 35. A higher score indicated a higher perception of
family exercise support. Cronbach's coefcient was 0.86.
Eligibility
Assessment (n=375)
Excluded (n=273)
Not failing inclusive criteria (n=102)
No LBP: n=87
Multiparaous: n=10
Unable to read in Chinese: n=3
Twins: n=2
Reject (n=171)
No time: n=86
Not allow exercise: n=85
102 eligible postpartum
women allocated to study
groups by self-selection
Intervention (stability
ball exercise) group
(n=51)
Control (Standard
care) group (n=51)
Six participants were
excluded due to:
Preterm labor (n=2, 3.9%)
Uterine contraction too
frequencies (n=2, 3.9%)
Loss of contact (n=2, 3.9%)
Seven failure to follow up due
to:
Preterm labor (n=3, 5.9%)
Uterine contraction too
frequencies (n=2, 3.9%)
Bleeding (n=1, 2%)
Loss of contact (n=1, 2%)
45 in primary analysis 44 in primary analysis
Fig. 1. Passage of participants through each trial stage.
C.-F. Yan et al. / Midwifery () 3
Please cite this article as: Yan, C.-F., et al., Effects of a stability ball exercise programme on low back pain and daily life interference
during pregnancy. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.04.011i
Data collection
The respective school and hospital ethics committees approved
the study. All participants provided their written informed con-
sent. To maintain condentiality, completed questionnaires were
given a code number, which was kept in a locked le and viewed
only by the investigators. Pilot testing was conducted to determine
the amount of time required for the entire formal process, and its
feasibility in performing stability ball exercises.
In the formal study, the PI contacted all participants during the
antenatal childbirth education class and informed them about the
study. If participants agreed to participate, they received a letter
explaining the study as well as a consent form; all participants
then completed, on paper, a pretest about low back pain, family
exercise support attitudes in pregnancy, and demographic
information (T1).
The PI instructed the experimental group members, demon-
strating proper form during stability ball exercises. In total,
approximately one hour was spent highlighting the primary points
of the booklet contents. Subsequently, they could take home a
demonstration CD, booklet, and a stability ball for practising the
exercises. In ensuring the safety of themselves and that of their
fetus, they were instructed to monitor and record their heart rate
and practise the movements three times a week. In contrast,
control group women did not receive the exercise programme.
Both groups received standard nursing care from hospital staff
nurses for all aspects of pregnancy.
Members of both the experimental and control group com-
pleted the BPI-SF and FESAQ in the outpatient clinic at 2628
weeks (T2), 3032 weeks (T3), and 3436 weeks (T4) of gestation.
The PI collected all materials.
Ethical considerations
After receiving approval from the institutional review boards
(IRBs) and prior to data collection, the PI visited the antenatal
outpatient unit and childbirth education unit to explain the
research purpose and methodology to nursing managers, nurse
clinicians, and obstetricians. Potential participants who met the
study criteria were fully informed of the research purposes,
intervention benets/risks, procedures, and then asked to sign a
consent form. Condentiality was ensured, with subjects informed
of their right to withdraw at any point without affecting
subsequent care.
Statistical analysis
The demographic and pain characteristics of participants were
collected using descriptive statistics. The means and standard
deviations of continuous variables along with the frequencies
and percentages of dichotomous variables were calculated using
SPSS (version 17.0 for Windows; SPSS Inc., Chicago, Illinois).
Differences in demographic and obstetric variables between
groups were evaluated with
2
or independent t-tests. Qin et al.
(2008) indicated that a lack of randomisation of nursing interven-
tion in outcome effectiveness studies may lead to imbalanced
covariates. Thus, propensity score analysis was used (Qin et al.,
2008) to adjust the inequality of the underlying exercise patterns.
This method features a weighted analysis, directly comparing the
means marginalised over the imbalanced covariates to yield
unbiased estimates of the intervention programme's effect. Each
participant is assigned a weight value (W
i
) equal to the inverse of
the propensity score for two study groups (X
i
) based on
Table 1
Stability ball exercise protocol.
Exercise Main muscles Purpose Frequency
Seated on the stability ball
1. Pelvic circling and rocking Lumbar, hip joints, and core muscles Exercise lumbar muscles and hip joints; relax pelvic oor
muscles and reduce LBP
68 times for each move
2. Forward abdominal and
pelvic muscle exercises
Pelvic oor muscles Awaken the proprioception of pelvic oor muscles. 8 times while maintaining a
steady contraction for
5 seconds
3. Side bends and head turns Muscle groups around the abdomen,
lumbar, and cervix.
Activate the abdominal wall musculature; exercise and relax
lumbar and cervix area muscles; reduce LBP
4 rounds, holding each
move for 4 seconds
4. Forward shoulder press Shoulder posterior (infraclavicular
triangle, rhomboid muscles, and
trapezius muscles)
Enhance posterior shoulder muscle endurance and relax back
muscles
68 times for 12 rounds
5. Chair pose Posterior shoulder, upper back, and
spinal area muscles
Strengthen shoulder and dorsum muscle groups and reduce
LBP; enhance upper body strength
46 rounds, with each move
held for 4 seconds
Standing
6. Wall squats Lower extremities (hips, thighs, calves) Strengthen lower extremity muscle groups; prevent varicose
veins and leg spasms
68 times for 12 rounds
7. Saw position ball clasp Core muscles Contraction exercise for core muscles; enhance joint stability 68 times for 12 rounds
8. Forward bending (Cat) Spine Enhance spinal mobility; Strengthen pelvic oor and stabilise
spine
68 times
9. Forward bending ball lift Deltoid muscle, bicipital muscle, and
core muscles
Enhance anterior shoulder and core muscle endurance;
enhance upper body strength
68 times for 12 rounds
Supine/oor seated position
10. Bridge Gluteus maximus and hamstring
muscles
Strengthen back and hip muscles; improve water retention in
lower extremities; prevent varicose veins
68 times for 12 rounds
11. Supine left-to-right
rocking+sideways fall
Hip joint, thigh, and core muscles Relax hip area muscles and stimulate core muscles; enhance
lower-extremity circulation; reduce discomfort from water
retention
68 full cycles for 12
rounds
12. Spinal twist Spine and core muscles Enhance spine lateral mobility; increase core muscle
endurance; and improve LBP
68 full cycles for 12
rounds
13. Spinal stretch Spine and posterior thigh muscles Enhance spine sagittal mobility; increase posterior thigh
exibility; and improve LBP
68 times
14. Shoulder and chest stretch
and release while seated
against a wall
Shoulder and chest Stretch shoulder and chest muscles and increase exibility;
prevent the onset of kyphosis
46 rounds, with each move
held for 4 seconds
C.-F. Yan et al. / Midwifery () 4
Please cite this article as: Yan, C.-F., et al., Effects of a stability ball exercise programme on low back pain and daily life interference
during pregnancy. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.04.011i
demographic and obstetric variables (Z
i
); for example, W
i
1/Pr
[X
i
x
i
|Z
i
z
i
]. The generalised estimating equations (GEE) model
controlled the effect of study covariates and analysed the inde-
pendent effect of stability ball exercises. The level of signicance
was set at 0.05, one tailed.
Findings
Among the 89 trial participants, the average age was 30.44
(SD3.32) years. Most had graduated from university (n40,
44.9%). Their heights ranged from 147170 cm (mean159.37;
SD5.16). The average pre-pregnancy weight and BMI were
54.68 kg (SD9.03) and 21.53 (SD3.4), respectively. The average
total pregnancy weight gain was 14.75 kg (SD3.4). The groups
displayed no statistical differences in demographic and obstetrical
variables (p40.05) (Table 2).
The effect of stability ball exercises on LBP and daily life
function interference (DLFI) was measured using the BPI-SF. At
baseline (2224 gestational weeks), the mean LBP score for the
intervention group was 4.04 (SD3.55) compared with 5.18
(SD3.67) for the control group. On the 28th, 32th, and 36th
gestational weeks, mean LBP scores for the experimental group
had risen slightly, whereas the control group had risen signi-
cantly (Table 3 and Fig. 2). GEEs evaluated the differences after
adjusting for several variables with potential effects on LBP. Table 4
shows how changes for mean LBP were signicantly lower in the
intervention group (2.65, po0.01) than the control. Time-
dependent changes also indicate that post-test LBP values rose an
average 4.308.59 points over pretest results, implying a growth
effect. However, the interaction effect (group difference and time)
revealed that the intervention group achieved a signicantly
greater drop in LBP values compared to their control group peers
over time (2.377.07, po0.01).
The same pattern was found in the daily life function inter-
ference (DLFI). At baseline (2224 gestational weeks), the mean
DLFI score for the experimental group was 17.73 (SD11.99)
compared to 24.25 (SD12.30) for the control group. On the
28th, 32nd, and 36th gestational weeks, mean DLFI scores for
the experimental group had fallen slightly, whereas the control
group had risen signicantly (Table 3 and Fig. 2). GEEs evalua-
ted differences after adjusting for several variables with potential
effects on DLFI. Table 4 shows how changes for mean DLFI were
signicantly lower in the intervention group (4.63, po0.05)
than the control. Time-dependent changes also indicate that
post-test DLFI values rose an average 6.5811.72 points over
pretest results, implying a growth effect. However, the interac-
tion effect (group difference and time) revealed that subjects in
the intervention group achieved a signicantly greater drop
in DLFI values compared to their control group peers over time
(12.6920.32, po0.001).
Discussion
Low back pain (LBP) is one of the most common complaints in
antenatal care. In this cohort, we observed an incidence of 76.8% at
2022 weeks of gestational age (no LBP87/375, Fig. 1). These
high proportions of LBP complaints conform to those of previous
studies (Wang et al., 2004; Ansari et al., 2010). As expected,
as pregnancy progressed, a signicant positive linear trend in
the LBP and body weight was observed (Tables 2 and 3). Ho (2008)
indicated that pregnancy is associated with increased trunk mass,
which may lead to postural alterations. Such changes related to the
Table 2
Participant background, exercise information, and family exercise support attitude.
Overall (N89) Control group (n44) Intervention group (n45) Statistics p
N % n % n %
Age (M, SD) 30.44 3.32 29.77 3.58 31.09 2.95 1.90
n
0.061
Education 7.17

0.067
High school 18 20.2 13 29.5 5 11.1
Junior College 21 23.6 12 27.3 9 20.0
University 40 44.9 16 36.4 24 53.3
Masters and above 10 11.2 3 6.8 7 15.6
Height (cm, M, SD) 159.37 5.16 158.76 4.58 159.97 5.67 1.10
n
0.273
Weight (kg, M, SD)
Pre-pregnancy 54.68 9.03 54.27 9.20 55.09 8.97 0.42
n
0.673
Gestational weeks 2022 57.73 9.54 57.05 9.93 58.40 9.20 0.66
n
0.508
Gestational weeks 24 59.97 9.76 59.24 10.11 60.68 9.47 0.70
n
0.487
Gestational weeks 28 62.29 9.90 61.54 10.13 63.02 9.73 0.71
n
0.482
Gestational weeks 32 64.70 9.95 64.21 10.29 65.21 9.68 0.46
n
0.647
Gestational weeks 36 67.07 9.95 66.92 10.25 67.25 9.73 0.15
n
0.880
Gestational weeks 40 69.45 10.17 69.68 10.46 69.20 9.95 0.21
n
0.832
Total weight gain 14.75 3.40 15.40 3.61 13.99 3.01 1.91
n
0.059
Pre-pregnancy BMI (M, SD) 21.53 3.40 21.50 3.36 21.55 3.47 0.07
n
0.945
Regular physical activity status (Yes, %)

Pre-pregnancy 34 38.2 16 36.4 18 40.0 0.13

0.724
Gestational weeks 2224 (baseline) 19 20.9 7 15.9 12 25.5 1.27

0.259
Gestational weeks 2628 55 61.8 11 25.0 44 97.8 49.91

o0.001
Gestational weeks 3032 51 57.3 12 27.3 39 86.7 32.08

o0.001
Gestational weeks 3436 48 53.9 10 22.7 38 84.4 34.11

o0.001
Family exercise support attitude
Baseline (2224 weeks) 16.67 7.00 13.82 5.49 19.47 7.24 4.15
n
o0.001
Gestational weeks 2628 17.00 7.08 12.98 5.53 21.02 6.14 6.46
n
o0.001
Gestational weeks 3032 17.78 7.95 12.95 5.87 22.95 6.52 7.44
n
o0.001
Gestational weeks 3436 18.45 8.36 12.80 5.22 25.00 6.26 9.50
n
o0.001
n
Independent t-test.

2
test.

Accumulating 30 minutes or more of moderate intensity exercise on most days of the week.
C.-F. Yan et al. / Midwifery () 5
Please cite this article as: Yan, C.-F., et al., Effects of a stability ball exercise programme on low back pain and daily life interference
during pregnancy. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.04.011i
shifting of the centre of gravity have been postulated as one of the
major causes of LBP during pregnancy.
Previous studies have indicated that exercise during pregnancy
is safe and benecial to both mother and fetus (Berk, 2004; Downs
and Hausenblas, 2007; Yeo, 2010). The American College of
Obstetricians and Gynecologists (ACOG) (2002) has advised preg-
nant women without medical or obstetric complications to engage
in regular physical activity. Their target exercise regimen is 30
minutes or more of moderate daily exercise on most, if not all,
days of the week (American College of Obstetricians and
Gynecologists (ACOG), 2002; Zavorsky and Longo, 2011). However,
during the subject recruitment phase, 85 of the 375 pregnant
women (22.67%, Fig. 1) refused participation due to exercise
taboos. Moreover, a large proportion of our sample group who
had conducted regular weekly exercises prior to pregnancy
reported no physical activity nor had substantially reduced their
exercise levels following pregnancy. Table 2 shows that our study
had a higher proportion of sedentary subjects (74.584.1% for the
control group) compared to previous studies reporting a sample of
60% inactive pregnant women (Hausenblas and Downs, 2004;
Marquez et al., 2009).
There were three potential rationales to explain these ndings.
First, in Chinese culture, habitual weekly exercise during pregnancy
has been discouraged due to concerns about Tai-Shen or Tai-Qi
(fetus spirit), leading to suboptimal fetal and maternal outcomes
(Sung, 1996). Second, Taiwan is characterised by a low birth rate,
which means that pregnant women are often highly appreciated and
protected (Chang, 2011). In addition, Chinese culture emphasises
care-taking of pregnant women. Such factors adversely impact
exercise behaviours among the sampled pregnant women (Chang,
2011). Third, besides these cultural aspects, social support for exercise
also inuenced participants motivations and beliefs about the need
to perform physical activities and/or exercises. Our study found that
the experiment group had more positive family exercise support
attitude scores and was more active overall than the control group.
These results were consistent with previous studies, suggesting that
social support is a main psychological and physical-health determi-
nant (Albright et al., 2005; Thornton et al., 2006). Albright et al.
Table 3
Differences in low back pain and daily life interference between the two sample groups (N89).
Variable Overall mean SD Experimental group mean SD Control Group mean SD t p
Low back pain
Baseline (2224 weeks) 8.63 (4.47) 7.67 (4.68) 9.61 (4.07) 1.486 0.141
28 weeks 11.51 (4.66) 9.11 (4.04) 13.91 (3.98) 5.611 o0.001
32 weeks 12.55 (6.38) 8.12 (4.43) 16.68 (5.00) 8.330 o0.001
36 weeks 13.77 (6.31) 8.63 (4.86) 18.20 (3.35) 10.50 o0.001
Daily life interference
Baseline (2224 weeks) 20.96 (12.51) 17.73 (11.99) 24.25 (12.30) 2.532 0.013
28 weeks 24.16 (15.74) 12.25 (8.99) 36.07 (11.40) 10.884 o0.001
32 weeks 27.13 (18.20) 11.00 (8.96) 42.16 (9.67) 15.383 o0.001
36 weeks 29.50 (20.78) 9.79 (9.56) 46.52 (9.74) 17.178 o0.001
7.67
9.11
8.12
8.63
9.61
13.91
16.68
18.20
0.00
5.00
10.00
15.00
20.00
25.00
30.00
L
o
w

B
a
c
k

P
a
i
n
Gestational Weeks
Control
Experimental
17.73
12.25
11.00
9.79
24.25
36.07
42.16
46.52
0.00
10.00
20.00
30.00
40.00
50.00
60.00
2
6
-
2
8

w
e
e
k
s
3
0
-
3
2
w
e
e
k
s
D
a
i
l
y

L
i
f
e

F
u
n
c
t
i
o
n

I
n
t
e
r
f
e
r
e
n
c
e
Gestational Weeks
Control
Experimental
2
2
-
2
4

w
e
e
k
s
3
4
-
3
6

w
e
e
k
s
Fig. 2. Changes in low back pain and daily life function interference during baseline (2224 weeks) and posttests.
Table 4
Generalised Estimating Equations Model
n
on the effect of outcome variables for
stability ball exercises (N89).
Variables SE p
Low back pain
Group (experimental versus control) 2.65 0.98 0.007
Time (gestational weeks)
Baseline (2224 weeks) Reference
28 weeks 4.30 0.56 o0.001
32 weeks 7.07 0.93 o0.001
36 weeks 8.59 0.58 o0.001
Grouptime
Groupbaseline (2224 weeks) Reference
Group28 weeks 2.37 0.88 0.007
Group32 weeks 5.96 1.22 o0.001
Group36 weeks 7.07 1.02 o0.001
Daily life interference
Group (experimental versus control) 4.63 1.96 0.016
Time (gestational weeks)
Baseline (2224 weeks) Reference
28 weeks 6.58 2.06 0.001
32 weeks 9.23 2.07 o0.001
36 weeks 11.72 2.83 o0.001
Grouptime
Groupbaseline (2224 weeks) Reference
Group28 weeks 12.69 2.25 o0.001
Group32 weeks 15.77 2.50 o0.001
Group36 weeks 20.32 2.94 o0.001
n
All models adjusted for age, weight, education, occupation, pre-pregnancy
BMI, pre-pregnancy exercise status, and family exercise support attitude by
propensity score.
C.-F. Yan et al. / Midwifery () 6
Please cite this article as: Yan, C.-F., et al., Effects of a stability ball exercise programme on low back pain and daily life interference
during pregnancy. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.04.011i
(2005) surveyed 79 new mothers to determine their physical activity
patterns as well as barriers and facilitators of physical activity before
and after childbirth. The most frequently-mentioned factor that
would empower women to be more active was social support. To
investigate this further, a community-based participatory project was
conducted in southwestern Detroit to investigate the inuence of
social support on weight, diet, and physical-activity related beliefs
and behaviours among pregnant and postpartum Hispanic women
(Thornton et al., 2006). The results indicate that the absence of
exercise partners was a prominent barrier limiting a women's ability
to consistently perform physical activities during and after
pregnancy.
These ndings indicate that stability ball practice during
pregnancy may not only facilitate exercise behaviour, but also
reduce low back pain and daily life function interference. During
the third trimester of pregnancy, regular stability ball exercises
improved muscular alignments and posture as well as induced
changes to the body's centre of gravity (Watkins, 2001). These
exercises mobilise the lumbrosacral fulcrum and sacroiliac cox-
ofemoral articulations, maintaining muscle tone in the oblique,
and transversing abdominal muscles (Perez, 2000). Consistent
practice helps expectant mothers to reduce low back pain as they
grasp how to maintain good posture and core strength (Perez,
2000; Watkins, 2001). Pregnancy induces stark physical changes
and low back pain may challenge female morbility level, leading to
difculties in performing daily activities (Sung, 1996; Sydsjo et al.,
1998; Albright et al., 2005). Following a 12-week exercise pro-
gramme, improvements were observed in the daily life functions
for experimental group women. In contrast, control group women
experienced increased limitations to daily life over the course of
pregnancy.
Additional research has indicated that individuals who exercise
are more likely to take responsibility for their health and engage in
proactive healthy behaviour, therefore improving their daily life
function and life quality (Smith and Michel, 2006; Montoya et al.,
2010). Smith and Michel (2006) studied the impact of aquatic
exercise programmes on perceptions of body image, participation
in health-promotion, levels of physical discomfort, and mobility.
Participants in exercise groups reported signicantly less physical
discomfort, improved mobility, and improved health-promoting
behaviours compared to control subjects. Meanwhile, using an
experimental pretest/post-test design, Ostgaard et al. (1994)
demonstrated that participants who exercised reported a lower
incidence of back pain and reduced sick leave absences due to
pregnancy-induced back pain.
Conclusion
In summary, this study suggests that the clinical implementa-
tion of a stability ball exercise programme could be an effective
adjunctive tool for second- and third-trimester women in improv-
ing exercise behaviour, reducing low back pain, and diminishing
daily life interference. Health professionals may uncover three
major implications. First, although previous studies have moni-
tored and revealed the benets of exercise during pregnancy,
Chinese women have traditionally been advised to follow seden-
tary lifestyles by their family members during pregnancy due to
concerns about maternal and fetal health. Therefore, nurses and
childbirth educators must provide pregnant women and their
family members with information on the benets of exercise at
least ve times/week for 30 minutes/time. Second, for Chinese
individuals, social relationships are particularly relevant to health
since the extended family has traditionally played an integral role
in daily life (Kwong and Kwan, 2007; Chen, 2009). In this study,
family attitudes towards exercise may facilitate exercise behaviour.
Culturally-relevant intervention strategies should focus on family
health in an effort to revise entrenched beliefs and promote
individual exercise habits during pregnancy. Third, based upon
the effectiveness of this stability ball exercise programme to LBP,
the health-care professionals may introduce it into postnatal
classes to encourage the continuation of the exercises. Future
studies may investigate the effectiveness of the programme to
postnatal period in terms of LBP, stress urinary incontinence, and
weight loss.
Several limitations were inherent to this study. Firstly, due to
cultural and ethical issues, the non-randomised group assignment
should experience an internal validity of the interpretations. The
participants self-selection of group assignment may be a con-
founding variable that contributed to a bias. While no group
differences were identied among demographics, obstetrics, or
pre-pregnancy exercise status, this small sample size does not
assure that group differences are indeed irrelevant. In response, a
propensity score analysis was used to adjust the inequality of the
participant's underlying exercise pattern. Secondly, because a
primary investigator conducted the interventions and data collec-
tion, observer bias was unavoidable. The participants in the
intervention group may have answered questions in a manner
geared towards approval seeking or receiving the favour of the
researchers. Thirdly, due to time limitations, neonatal birth out-
comes went unobserved; therefore we suggest further investiga-
tion into the pregnancy effects, if any, of our exercise programme,
e.g. gestational weeks, birth weight, and Apgar scores. Lastly, since
the study was conducted in a regional hospital in northern Taiwan
with nullipara women, caution should be taken in generalising
ndings to other settings and multiparaous women.
Conict of interest
None declared.
Ethical approval
IRB approved by National Taipei College of Nursing NTCNNM-
9801.
Acknowledgement
The authors wish to express their greatest appreciation to the
women who agreed to participate in this study. The assistance of
the nursing staff and administrators of the Bin-Kun Women &
Children's Hospital in recruiting women is also gratefully
acknowledged.
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C.-F. Yan et al. / Midwifery () 8
Please cite this article as: Yan, C.-F., et al., Effects of a stability ball exercise programme on low back pain and daily life interference
during pregnancy. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.04.011i