Effectiveness of the Resistance Exercises with Motor Skills Training and Pain Reprocessing on Pain, Performance, and Psychological Factors in Flight Attendants with Non-Specific Low Back Pain: Study Protocol for a Randomised Controlled Trial

Effectiveness of the Resistance Exercises with Motor Skills Training and Pain Reprocessing on Pain, Performance, and Psychological Factors in Flight Attendants with Non-Specific Low Back Pain: Study Protocol for a Randomised Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Effectiveness of the Resistance Exercises with Motor Skills Training and Pain Reprocessing on Pain, Performance, and Psychological Factors in Flight Attendants with Non-Specific Low Back Pain: Study Protocol for a Randomised Controlled Trial Negin Zolfaghari, Amir Letafatkar, Giacomo Rossettini This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4485068/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Low back pain (LBP) is one of the prevalent chronic pains in flight attendants. Exercise is recommended; however, the effects of resistance exercises with motor skills training and pain reprocessing in flight attendants with LBP are not currently known. This study compares the effect of resistance exercises with motor skills training and pain reprocessing on the pain, performance, and psychological factors of flight attendants with LBP. Methods This study is a randomized controlled trial in which 60 flight attendants with LBP will be enrolled. The patients will be randomly allocated to receive (1) resistance exercises plus motor skill exercises, (2) resistance exercises plus pain reprocessing, (3) resistance exercises plus motor skill exercises and pain reprocessing and (4) resistance training. Participants will be assessed pre- and post-intervention and 3 months after interventions. The primary outcome will be pain intensity. The secondary outcomes will be disability, quality-of-life, fear of movement, pain catastrophizing, pain self-efficacy, depression, anxiety, stress, performance, single-limb stance, sitting on Bobath ball and muscular endurance at post-intervention and 3 months. Discussion This study will be the first to compare resistance training with motor skills training and pain reprocessing on pain, performance and psychological factors of flight attendants with LBP. As this research is being conducted in one of the low-income countries, the demographic characteristics and results may differ from those of high-income countries. Results may guide clinicians and improve their clinical outcomes when treating flight attendants with LBP. Trial registration: The protocol was registered prospectively on Clinical Trials (IRCT20220804055617N1, Registration Date: 17/12/2022, http://www.irct.ir ). disability muscular endurance non-specific low back pain pain pain neuroscience education psychological factors Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Low back pain (LBP) is the most prevalent chronic pain in flight attendants [ 1 ]. LBP is one of the most common and demanding problems in primary and secondary care as it causes disability, reduces the quality of life, and prevents participation in usual activities [ 2 , 3 ]. LBP is not only mechanically related to spinal pathophysiology (i.e., muscle weakness) [ 4 ] but may also be influenced by attitudes, beliefs, and behaviours [ 5 , 6 ]. Psychological factors, such as fear-avoidance beliefs, unoptimal coping strategies, and mood changes, seem to be important determinants of chronic symptoms, disability, and perception [ 7 ], and it is now widely recognized that kinesiophobia plays a central role in its development and persistence [ 8 , 9 ]. Exploration of the thoughts of people disabled by LBP has uncovered that many endorse disproportionately strong beliefs about the importance of back pain and the vulnerability of the spine and, as a consequence, avoid activities they fear will lead to additional pain and injury [ 10 , 11 ]. The consequences of elevated fear-avoidance beliefs are most sizable in chronic LBP, where these beliefs are strongly associated with disability. This association persists even after controlling for pain intensity and other important covariables [ 11 – 13 ]. Poor movement patterns can lead to back disorders. Control of quality of movement patterns in resistance training is more challenging than in other types of exercise and could thus represent a good strategy for treating LBP [ 14 ]. The training should be (1) based on the person’s specific clinical presentation and limitations and (2) reinforced with repeated performance of functional activities across the day to facilitate learning [ 15 ]. On the other hand, leading psychological interventions for pain typically present the causes of pain as multifaceted and aim primarily to improve functioning and secondarily to reduce pain. Pain reprocessing therapy emphasizes that the brain actively constructs primary chronic pain in the absence of tissue damage and that reappraising the causes and threat value of pain can reduce or eliminate it [ 16 ]. However, the effects of resistance training with motor skills training and pain reprocessing in patients with LBP are not currently known. We hypothesized that resistance exercises with motor skills training and pain reprocessing could improve pain, performance and psychological factors in flight attendants with LBP when compared with resistance exercises. Methods Study design This study is a factor-randomized study with double-blinded investigators in the Kharazmi University, Tehran, Iran. This study was assessed and approved by the Research Ethics Committees of the Sport Sciences Research Institute (Approval ID: IR.SSRC.REC.1401.048) prior to data collection. The study was registered prospectively on Clinical Trials (IRCT20220804055617N1, Registration Date: 17/12/2022, http://www.irct.ir ). The study will performed in accordance with the ethical standards in the World Medical Association Declaration of Helsinki [ 17 ]. Participants Participants who met the following inclusion criteria will be considered eligible for the study: male and female flight attendants with non-specific chronic LBP between 20 and 40 years old; LBP onset ≥ 6 months; Numeric rating scale score of LBP ≥ 5 [ 18 ]. Participants will be excluded due to the following conditions: history of any surgery and inflammatory diseases in the spine area, diagnosis of a serious disease that may cause LBP (e.g., acute fracture, spinal dislocation), history of any musculoskeletal abnormalities in the spine area, progressive neurological defects or severe neurological symptoms (e.g., fibromyalgia and rheumatic arthritis) [ 18 ]. Randomization Using random permuted blocks randomization (16 blocks with size 8), four treatment combinations are independently allocated (Fig. 1 ) to participants by 1:1:1:1 ratio (after the initial assessment). The random sequence list was generated by computer (Pocock SJ. Clinical Trials: A Practical Approach. Wiley; 1983) and using ( https://www.randomizer.org ). This step will be guaranteed by a blind assessor. The assessor will be blind to group allocation. Participants will not be blind to the study and grouping; however, they were not aware of which treatment will be considered therapeutic (There is an unavoidable risk of bias in this study where the intervention cannot be blinded to patients). Before the evaluation, the necessary training will be given to the outcome assessor on how to measure the outcomes to prevent any questions and answers between the assessor and the participants. Intervention Resistance exercises along with motor skill exercises group : people receive resistance exercises along with motor skill exercises. Resistance exercises: It includes exercises for the muscles of the trunk area, which is divided into 3 stages, each stage is gradually more difficult. All patients will begin with Phase 1 exercises. Training will be done three days a week and for eight weeks. 2–3 sets of 8–10 repetitions are performed 2–3 times a week. Motor skills training: will include motor skills training and challenging functional activities that are difficult to perform due to back pain [ 15 , 19 ]. Resistance exercises with pain reprocessing group : participants receive resistance exercises with pain reprocessing. Resistance exercises: include exercises for the muscles of the trunk area, which are divided into 3 phases, each phase is gradually more difficult. All patients will begin with Phase 1 exercises. Exercises will be done three days a week and for eight weeks. 2–3 sets of 8–10 repetitions are performed 2–3 times a week [ 15 ]. Pain reprocessing: involves education aimed at increasing patients' re-perception of primary chronic pain as a false alarm generated by the brain. Pain reprocessing shares concepts and techniques with existing treatments for pain and cognitive behavioral therapy for fear disorder [ 16 ]. Participants will complete 8 sessions of 1-hour individual therapy sessions with an experienced therapist twice weekly for 4 weeks. Techniques include (1) providing personal evidence for focused pain (2) guided reappraisal of pain sensation while sitting and while engaging in fearful situations or movements (3) techniques focusing on psychosocial factors (e.g., depression) that potentially increase pain, and (4) techniques to increase positive emotions and self-compassion. Resistance exercises with motor skill exercises and pain reprocessing group : participants receive resistance exercises with motor skill exercises and pain reprocessing. Resistance exercises: include exercises for the muscles of the trunk area, which are divided into 3 phases, each phase is gradually more difficult. All patients will begin with Phase 1 exercises. Exercises will be done three days a week and for eight weeks. 2–3 sets of 8–10 repetitions are performed 2–3 times a week. Motor skills training: will include motor skills education and challenging functional activities that are difficult to perform due to LBP [ 15 , 19 ]. Pain reprocessing: involves education aimed at increasing patients' re-perception of primary chronic pain as a false alarm generated by the brain. Pain reprocessing shares concepts and techniques with existing treatments for pain and cognitive behavioral therapy for the fear disorder. Participants will complete 8 sessions of 1-hour individual therapy sessions with an experienced therapist twice weekly for 4 weeks. Techniques include (1) providing personal evidence for focused pain (2) guided reappraisal of pain sensation while sitting and while engaging in fearful situations or movements (3) techniques focusing on psychosocial factors (e.g., depression) that potentially increase pain, and (4) techniques to increase positive emotions and self-compassion [ 16 ]. Resistance training group : Individuals will only receive resistance training. Resistance exercises: includes exercises for the muscles of the trunk area, which is divided into 3 stages, each stage is gradually more difficult. All patients will begin with Phase 1 exercises. Training will be done three days a week and in eight weeks. 2–3 sets of 8–10 repetitions are performed 2–3 times a week [ 15 ]. Main outcome variables Primary outcomes Pain The Visual Analogue Scale (VAS) will be used to evaluate patients’ current pain intensity, where 0 signified no pain and 10 signified the worst imaginable pain [ 20 ]. The minimal clinically important difference (MCID) of 2 points has been reported for the LBP [ 21 , 22 ]. Secondary outcomes Quality Of Life Quality of life will be assessed using the Persian version of the self-reported Short-Form (36) Health Survey (SF-36) (minimum score = 0, total maximum score = 100, with a higher score indicating better quality of life) with physical and mental component scores also calculated. The SF-36 is a validated multipurpose, short-form health survey with 36 questions and is the most widely used [ 23 ]. Disability Disability will be assessed using the Persian version of the Roland–Morris disability questionnaire (RMDQ). The RMDQ consists of 24 statements about activity limitations due to back pain, e.g., walking, lying, and self-care. The RMDQ overall score ranges from 0 to 24 points, and a higher score represents more severe disability. It is suggested that the MCID of improvement of the RMDQ is 4, which would be clinically meaningful in LBP patients [ 24 ]. Fear of movement Fear-avoidance beliefs will be measured with the Persian version of the 16-item Fear-Avoidance Beliefs Questionnaire (FABQ). Higher aggregate scores indicate stronger fear-avoidance beliefs. Two subscales within the FABQ are work (seven-question FABQ-W, scores 0–42), and physical activity (four-question FABQPA, scores 0–24). FABQ-W assesses the fear of losing work because of pain, and the FABQ-PA assesses the relationship between physical activity and pain exacerbation [ 25 ]. A change of 4 points for FABQ-PA and 7 points for FABQ-W were recommended as MCID [ 26 ]. Pain Catastrophizing Pain catastrophizing will be measured using a Persian version of the Pain Catastrophizing Scale, which consists of 13 descriptions of pain experience [ 27 ]. Each item is rated according to the respondent’s perceived thoughts and feelings while experiencing pain. The total score ranges from 0 to 52, with higher scores indicating more catastrophic thoughts [ 28 , 29 ]. Pain Self-Efficacy Pain self-efficacy will measure with the Persian version of Pain Self-efficacy Questionnaire (PSEQ), which consists of 10 items scored on a 7-point Likert scale (0–6 points). Scores range from 0 to 60, with the higher scores indicating stronger self-efficacy beliefs [ 30 ]. The MCID for clinical relevance in this study is considered to be 9 points [ 31 ]. Depression, Anxiety, Stress The Persian version of the Depression Anxiety Stress Scale (DASS) is a low-cost, easy-to-use scale which allows for a rapid assessment of depression, anxiety, and stress. The items of the scale are rated on a 4-point Likert scale, with the score for each item ranging from 0 (does not apply to me at all) to 3 (applies to me most of the time). The subscale scores were calculated by summing the scores of the individual items and the maximum sum for each subscale is 21; a higher score indicates a worse emotional condition [ 32 ]. A minimum of 5 points change is recommended to achieve MCID of DASS in patients with LBP [ 33 ]. The fingertip-to-floor test (flexion ROM) The patient will stand erect on a 20 cm-high platform with shoes removed and feet together. The patient was asked to bend forward as far as possible while maintaining the knees, arms, and fingers fully extended. The vertical distance between the tip of the middle finger and the platform was measured in centimetres (Fig. 2 ) [ 34 ]. Single Limb Stance The single-leg stance test [ 35 ] will be used to assess static postural and balance control. Perform with eyes open and hands on the hips. The patient will be asked to flex one hip between 60 and 90 and maintain this position for 30 seconds. The patient stands on one leg unassisted; time begins when the opposite foot leaves the ground; time stops immediately when the opposite foot touches the ground and/or when hands leave the hips (Fig. 3 ). Sitting On Bobath Ball The patient will sit on a Bobath ball one metre in front of a checked curtain so that one of the longitudinal lines of the curtain was in line with the spine. The raters will be positioned about two metres behind the patient, as close to the patient’s midline as possible. The raters will be kneeling down so that the eyes of the raters are in a horizontal line with the patient's lower back. The diameter of the ball will be 65 cm. However, for patients shorter than 160 cm, a ball 55 cm in diameter will used and for patients taller than 190 cm, the diameter of the ball will be 75 cm. The dorsal sides of the patient's hands will be loosely placed on his/her thighs. There will be approximately 5 cm between the feet, and the calves will not touch the ball. The patient will then be asked to lift his/her foot and keep it about 5 cm above the floor for 20 seconds (Fig. 4 ). The test will be evaluated as negative if the spine will keep in its original vertical position for 20 seconds and if no compensatory movements will be made by the lifted leg or by the arms. A short change from the starting position will accept as long as this position is quickly resumed. Positive if: the spine deviates from the original vertical position and/or compensatory movements will be made by the lifted leg or by the arms and/or two or more short changes from the starting position. Not valid if the patient did not manage to perform the test due to pain [ 36 ]. Muscular Endurance The torso muscular endurance will be assessed by using the McGill Core Endurance Tests [ 37 ]. The flexor endurance test is the first in the battery of three tests (trunk flexor endurance, trunk lateral endurance, and trunk extensor endurance tests) that assess the muscular endurance of the core muscles (Fig. 5 ). It is a timed test involving a static, isometric contraction of the anterior muscles, stabilizing the spine until the individual exhibits fatigue and can no longer hold the assumed position. All the McGill Core Endurance Tests will be explained to patients first, and then the tests will be performed. Data collection and statistical analysis An analysis using G*Power (3.1.9.2, Dusseldorf, Germany) concludes that sufficient power (0.8) is achieved with the primary outcome variable [ 38 ], estimated sample size of 60 participants, alpha of 0.05, and estimated effect size (f = 0.25). The data will be analysed by intention-to-treat (ITT) and by a statistician blinded to group allocation. A mixed linear model will be used to assess the effect of treatment on outcomes and to fit a repeated-measures analysis of variance. Estimates of the effect of the intervention and 95% CI will be estimated by constructing linear contrasts to compare the adjusted difference in means or proportions at each time point between the treatment and control groups. Statistical significance will be set a priori at ≤ 0.05. SPSS V.25.0 will be used to complete data processing and statistical analysis. Adverse events and serious adverse events In this study, data on adverse events will be collected based on patient reports and investigator observations. In addition, we will analyse the incidence of adverse events, abnormal laboratory parameters, and serious adverse events suspected to be related to the treatment. The causality between the treatment and the adverse events will be assessed using a 6-point scale based on the causality assessment system of the World Health Organisation-Uppsala Monitoring Centre. Monitoring and trial management The Trial Management Group will provide trial oversight and monitor any safety issues that arise. Discussion The aim of this protocol study is to evaluate the effects of resistance exercises with motor skills training and pain reprocessing on pain, performance and psychological factors in flight attendants with LBP. Identification of relevant motor control features or a specific response to a movement test can inform specific movements and exercise therapy, with a rapid response for some patients. Other patients may have a presentation complicated by features such as differences in pain processing, experience of intense pain, fear avoidance, and previous experiences that compromise their full participation in physical treatments. These patients may benefit from coordinating physical and medical treatments to fully recover from an episode of LBP and establish a maintenance program and future self-management of LBP episodes [ 14 ]. In people with LBP, psychological factors are important predictors for long-term disability, and pain-related fear is often more disabling than the pain itself [ 7 ]. Indeed, it is assumed that fear-avoidance beliefs prevent subjects from regaining normal function by promoting the development of guarded movements and contributing to disability onset and persistence [ 39 – 41 ]. Despite several studies looking at factors associated with LBP, few intervention studies addressing these factors with adequate sample size have been performed [ 16 ]. This randomized clinical trial will be the first study to evaluate the resistance exercises with motor skills training and pain reprocessing program on pain, performance, and psychological factors in flight attendants with LBP. The results from this study will help researchers and physiotherapists improve clinical outcomes in patients with LBP. Trial status At the time of manuscript submission, participants had not yet been recruited. Participant recruitment is expected to start on 20 December 2025 and end on 20 December 2026. Data analysis is planned to start on 20 December 2026. Abbreviations LBP: Low Back pain VAS: Visual Analogue Scale MCID: Minimal Clinically Important Difference SF-36: Self-reported Short-Form Health Survey RMDQ: Roland–Morris Disability Questionnaire FABQ: Fear-Avoidance Beliefs Questionnaire PSEQ: Pain Self-efficacy Questionnaire DASS: Depression Anxiety Stress Scale ITT: Intention-to-treat Declarations Ethics approval and consent to participate This study was assessed and approved by the Research Ethics Committees of Sport Sciences Research Institute (Approval ID: IR.SSRC.REC.1401.048) prior to data collection. The study was registered prospectively on Clinical Trials (IRCT20220804055617N1, Registration Date: 17/12/2022, http://www.irct.ir). The study will perform in accordance with the ethical standards in the World Medical Association Declaration of Helsinki. Funding Not applicable. Authors' contributions NZ, AL and GR contributed to the original idea, study design and protocol, the conception of the work, conducting the study, revising the drafting and editing of the article. NZ, AL and GR contributed to the conception of the work, wrote, and editing of this article. All authors have read and approved the final version of the manuscript, and agree with the order of presentation of the authors. Acknowledgements Not applicable. Data availability No datasets were generated or analysed during the current study. Competing interests The authors declare no competing interests. References Rau P-LP, Tsao L, Dong L, Liu X, Ma L, Wang J: General and passenger-relevant factors of work-related musculoskeletal disorders (WMSDs) among Chinese female flight attendants . Work 2020, 66 (4):861-869. Deyo RA, Phillips WR: Low back pain: a primary care challenge . Spine 1996, 21 (24):2826-2832. Andersson GB: Epidemiological features of chronic low-back pain . The lancet 1999, 354 (9178):581-585. Heneweer H, Staes F, Aufdemkampe G, van Rijn M, Vanhees L: Physical activity and low back pain: a systematic review of recent literature . European Spine Journal 2011, 20 :826-845. Waddell G, Burton AK: Concepts of rehabilitation for the management of low back pain . Best Practice & Research Clinical Rheumatology 2005, 19 (4):655-670. Monticone M, Ferrante S, Rocca B, Baiardi P, Dal Farra F, Foti C: Effect of a long-lasting multidisciplinary program on disability and fear-avoidance behaviors in patients with chronic low back pain: results of a randomized controlled trial . The Clinical journal of pain 2013, 29 (11):929-938. Pincus T, Vlaeyen JW, Kendall NA, Von Korff MR, Kalauokalani DA, Reis S: Cognitive-behavioral therapy and psychosocial factors in low back pain: directions for the future . Spine 2002, 27 (5):E133-E138. John JN, Ugwu EC, Okezue OC, Ekechukwu END, Mgbeojedo UG, John DO, Ezeukwu AO: Kinesiophobia and associated factors among patients with chronic non-specific low back pain . Disability and Rehabilitation 2023, 45 (16):2651-2659. Varallo G, Giusti EM, Scarpina F, Cattivelli R, Capodaglio P, Castelnuovo G: The association of kinesiophobia and pain catastrophizing with pain-related disability and pain intensity in obesity and chronic lower-back pain . Brain Sciences 2020, 11 (1):11. Chou R, Shekelle P: Will this patient develop persistent disabling low back pain? Jama 2010, 303 (13):1295-1302. Rainville J, Smeets RJ, Bendix T, Tveito TH, Poiraudeau S, Indahl AJ: Fear-avoidance beliefs and pain avoidance in low back pain—translating research into clinical practice . The Spine Journal 2011, 11 (9):895-903. Woby SR, Watson PJ, Roach NK, Urmston M: Adjustment to chronic low back pain—the relative influence of fear-avoidance beliefs, catastrophizing, and appraisals of control . Behaviour research and therapy 2004, 42 (7):761-774. Elfving B, Andersson T, Grooten WJ: Low levels of physical activity in back pain patients are associated with high levels of fear‐avoidance beliefs and pain catastrophizing . Physiotherapy Research International 2007, 12 (1):14-24. Hides JA, Donelson R, Lee D, Prather H, Sahrmann SA, Hodges PW: Convergence and Divergence of Exercise-Based Approaches That Incorporate Motor Control for the Management of Low Back Pain . The Journal of orthopaedic and sports physical therapy 2019, 49 (6):437-452. van Dillen LR, Lanier VM, Steger-May K, Wallendorf M, Norton BJ, Civello JM, Czuppon SL, Francois SJ, Roles K, Lang CE: Effect of Motor Skill Training in Functional Activities vs Strength and Flexibility Exercise on Function in People With Chronic Low Back Pain: A Randomized Clinical Trial . JAMA neurology 2021, 78 (4):385-395. Ashar YK, Gordon A, Schubiner H, Uipi C, Knight K, Anderson Z, Carlisle J, Polisky L, Geuter S, Flood TF et al : Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial . JAMA psychiatry 2022, 79 (1):13-23. Association WM: World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects . JAMA 2013, 310 (20):2191-2194. Park KS, Kim S, Seo JY, Cho H, Lee JY, Lee YJ, Lee J, Kim MJ, Choi YE, Yang CS: Effectiveness and safety of pharmacopuncture therapy for chronic low back pain: a protocol for a pragmatic randomized controlled trial . Journal of Pain Research 2022:2629-2639. Lanier VM, Lang CE, Van Dillen LR: Motor skill training in musculoskeletal pain: a case report in chronic low back pain . Disability and rehabilitation 2019, 41 (17):2071-2079. Scrimshaw SV, Maher C: Responsiveness of visual analogue and McGill pain scale measures . Journal of manipulative and physiological therapeutics 2001, 24 (8):501-504. Crossley KM, Bennell KL, Cowan SM, Green S: Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid? Arch Phys Med Rehabil 2004, 85 (5):815-822. Piva SR, Gil AB, Moore CG, Fitzgerald GK: Responsiveness of the activities of daily living scale of the knee outcome survey and numeric pain rating scale in patients with patellofemoral pain . Journal of rehabilitation medicine 2009, 41 (3):129-135. Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B: The Short Form Health Survey (SF-36): translation and validation study of the Iranian version . Quality of life research 2005, 14 :875-882. Stratford PW, Binkley J, Solomon P, Finch E, Gill C, Moreland J: Defining the minimum level of detectable change for the Roland-Morris questionnaire . Physical therapy 1996, 76 (4):359-365. Waddell G, Newton M, Henderson I, Somerville D, Main CJ: A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability . Pain 1993, 52 (2):157-168. Monticone M, Frigau L, Vernon H, Rocca B, Giordano A, Simone Vullo S, Mola F, Franchignoni F: Reliability, responsiveness and minimal clinically important difference of the two Fear Avoidance and Beliefs Questionnaire scales in Italian subjects with chronic low back pain undergoing multidisciplinary rehabilitation . European journal of physical and rehabilitation medicine 2020, 56 (5):600-606. Ibrahim AA, Akindele MO, Kaka B, Mukhtar NB: Development of the Hausa version of the Pain Catastrophizing Scale: translation, cross-cultural adaptation and psychometric evaluation in mixed urban and rural patients with chronic low back pain . Health and Quality of Life Outcomes 2021, 19 :1-14. Picavet HSJ, Vlaeyen JW, Schouten JS: Pain catastrophizing and kinesiophobia: predictors of chronic low back pain . American journal of epidemiology 2002, 156 (11):1028-1034. Wertli MM, Eugster R, Held U, Steurer J, Kofmehl R, Weiser S: Catastrophizing—a prognostic factor for outcome in patients with low back pain: a systematic review . The Spine Journal 2014, 14 (11):2639-2657. Costa LdCM, Maher CG, McAuley JH, Hancock MJ, Smeets RJ: Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain . European Journal of Pain 2011, 15 (2):213-219. Maughan EF, Lewis JS: Outcome measures in chronic low back pain . European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 2010, 19 (9):1484-1494. Henry JD, Crawford JR: The short‐form version of the Depression Anxiety Stress Scales (DASS‐21): Construct validity and normative data in a large non‐clinical sample . British journal of clinical psychology 2005, 44 (2):227-239. Tagliaferri SD, Miller CT, Owen PJ, Mitchell UH, Brisby H, Fitzgibbon B, Masse‐Alarie H, Van Oosterwijck J, Belavy DL: Domains of chronic low back pain and assessing treatment effectiveness: a clinical perspective . Pain Practice 2020, 20 (2):211-225. Perret C, Poiraudeau S, Fermanian J, Colau MML, Benhamou MAM, Revel M: Validity, reliability, and responsiveness of the fingertip-to-floor test . Archives of physical medicine and rehabilitation 2001, 82 (11):1566-1570. Penney T, Ploughman M, Austin MW, Behm DG, Byrne JM: Determining the activation of gluteus medius and the validity of the single leg stance test in chronic, nonspecific low back pain . Archives of physical medicine and rehabilitation 2014, 95 (10):1969-1976. Tidstrand J, Horneij E: Inter-rater reliability of three standardized functional tests in patients with low back pain . BMC musculoskeletal disorders 2009, 10 :1-8. Dejanovic A, Cambridge ED, McGill S: Isometric torso muscle endurance profiles in adolescents aged 15–18: Normative values for age and gender differences . Annals of human biology 2014, 41 (2):153-158. Pardo GB, Girbés EL, Roussel NA, Izquierdo TG, Penick VJ, Martín DP: Pain neurophysiology education and therapeutic exercise for patients with chronic low back pain: a single-blind randomized controlled trial . Archives of physical medicine and rehabilitation 2018, 99 (2):338-347. Vlaeyen JW, Linton SJ: Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art . Pain 2000, 85 (3):317-332. Grotle M, Vøllestad NK, Brox JI: Clinical course and impact of fear-avoidance beliefs in low back pain: prospective cohort study of acute and chronic low back pain: II . Spine 2006, 31 (9):1038-1046. Burke AL, Mathias JL, Denson LA: Psychological functioning of people living with chronic pain: A meta‐analytic review . British Journal of Clinical Psychology 2015, 54 (3):345-360. Additional Declarations No competing interests reported. Supplementary Files CONSORT2010Checklist.doc SPIRITFillablechecklist11.12.2023.pdf TIDieRChecklistPDF27.5.2024.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4485068","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":318698214,"identity":"ad87f688-e758-4d91-9bab-988d52c64dcc","order_by":0,"name":"Negin Zolfaghari","email":"data:image/png;base64,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","orcid":"","institution":"Kharazmi University","correspondingAuthor":true,"prefix":"","firstName":"Negin","middleName":"","lastName":"Zolfaghari","suffix":""},{"id":318698215,"identity":"b259f3cd-cbfb-4e7e-b75f-67c746e0f19c","order_by":1,"name":"Amir Letafatkar","email":"","orcid":"","institution":"Kharazmi University","correspondingAuthor":false,"prefix":"","firstName":"Amir","middleName":"","lastName":"Letafatkar","suffix":""},{"id":318698216,"identity":"010783a8-de5c-4880-bdb2-72b85de74a99","order_by":2,"name":"Giacomo Rossettini","email":"","orcid":"","institution":"University of Verona","correspondingAuthor":false,"prefix":"","firstName":"Giacomo","middleName":"","lastName":"Rossettini","suffix":""}],"badges":[],"createdAt":"2024-05-27 12:40:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4485068/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4485068/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60186386,"identity":"2adecf95-5beb-43ce-942f-dcc332de8d5f","added_by":"auto","created_at":"2024-07-12 18:52:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":482618,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flow chart according to Consolidated Standards of Reporting Trials (CONSORT) statement.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4485068/v1/60a44968806d4bceca22def7.png"},{"id":60185952,"identity":"90e5f8a6-c24c-4b22-991c-23f68d24149c","added_by":"auto","created_at":"2024-07-12 18:44:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":923614,"visible":true,"origin":"","legend":"\u003cp\u003eThe fingertip-to-floor test [34].\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4485068/v1/351f29a5b942dc58c2313003.png"},{"id":60185956,"identity":"1bfe3ca6-5210-4378-8061-08c8e803fdaf","added_by":"auto","created_at":"2024-07-12 18:44:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":769523,"visible":true,"origin":"","legend":"\u003cp\u003eThe single leg stance test [35].\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4485068/v1/516f60059b0bfd7a4caf175d.png"},{"id":60185957,"identity":"48ff638b-feb1-4469-9edf-e6b26d883d79","added_by":"auto","created_at":"2024-07-12 18:44:45","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":339184,"visible":true,"origin":"","legend":"\u003cp\u003eSitting on Bobath Ball\u003cstrong\u003e \u003c/strong\u003etest [36]. (A) Negative and (B) Positive.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4485068/v1/37e784d3f3e1566d025e11e3.png"},{"id":60186387,"identity":"94880129-4a7e-4dc7-b1fc-6f95949141f8","added_by":"auto","created_at":"2024-07-12 18:52:45","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":3279486,"visible":true,"origin":"","legend":"\u003cp\u003eThe McGill Core Endurance Tests [37]. (A) trunk flexor endurance, (B) trunk lateral endurance, and (C) trunk extensor endurance.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-4485068/v1/d9b26b378510bf3eec8b4bd9.png"},{"id":64916877,"identity":"a097133c-ee51-4fb4-ac8f-e8c8a80eeaac","added_by":"auto","created_at":"2024-09-20 10:56:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":11324782,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4485068/v1/2b49528a-fdf6-41fd-a677-d901aaedbda4.pdf"},{"id":60185955,"identity":"fb7fc662-7530-4947-811f-023493082793","added_by":"auto","created_at":"2024-07-12 18:44:45","extension":"doc","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":224256,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORT2010Checklist.doc","url":"https://assets-eu.researchsquare.com/files/rs-4485068/v1/09a1c25310d4c868128adc4b.doc"},{"id":60185954,"identity":"0a48c63f-b25d-462c-8e26-b8b3df18f983","added_by":"auto","created_at":"2024-07-12 18:44:45","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":1062025,"visible":true,"origin":"","legend":"","description":"","filename":"SPIRITFillablechecklist11.12.2023.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4485068/v1/8d7d5abf298adae03d6ca5e5.pdf"},{"id":60185959,"identity":"3a910368-e588-44f3-9061-f2c9553066b7","added_by":"auto","created_at":"2024-07-12 18:44:45","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":427650,"visible":true,"origin":"","legend":"","description":"","filename":"TIDieRChecklistPDF27.5.2024.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4485068/v1/b9ada7153c53fc7b3aa1ad1f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of the Resistance Exercises with Motor Skills Training and Pain Reprocessing on Pain, Performance, and Psychological Factors in Flight Attendants with Non-Specific Low Back Pain: Study Protocol for a Randomised Controlled Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLow back pain (LBP) is the most prevalent chronic pain in flight attendants [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. LBP is one of the most common and demanding problems in primary and secondary care as it causes disability, reduces the quality of life, and prevents participation in usual activities [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. LBP is not only mechanically related to spinal pathophysiology (i.e., muscle weakness) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] but may also be influenced by attitudes, beliefs, and behaviours [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Psychological factors, such as fear-avoidance beliefs, unoptimal coping strategies, and mood changes, seem to be important determinants of chronic symptoms, disability, and perception [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and it is now widely recognized that kinesiophobia plays a central role in its development and persistence [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExploration of the thoughts of people disabled by LBP has uncovered that many endorse disproportionately strong beliefs about the importance of back pain and the vulnerability of the spine and, as a consequence, avoid activities they fear will lead to additional pain and injury [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The consequences of elevated fear-avoidance beliefs are most sizable in chronic LBP, where these beliefs are strongly associated with disability. This association persists even after controlling for pain intensity and other important covariables [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePoor movement patterns can lead to back disorders. Control of quality of movement patterns in resistance training is more challenging than in other types of exercise and could thus represent a good strategy for treating LBP [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The training should be (1) based on the person\u0026rsquo;s specific clinical presentation and limitations and (2) reinforced with repeated performance of functional activities across the day to facilitate learning [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. On the other hand, leading psychological interventions for pain typically present the causes of pain as multifaceted and aim primarily to improve functioning and secondarily to reduce pain. Pain reprocessing therapy emphasizes that the brain actively constructs primary chronic pain in the absence of tissue damage and that reappraising the causes and threat value of pain can reduce or eliminate it [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, the effects of resistance training with motor skills training and pain reprocessing in patients with LBP are not currently known. We hypothesized that resistance exercises with motor skills training and pain reprocessing could improve pain, performance and psychological factors in flight attendants with LBP when compared with resistance exercises.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study is a factor-randomized study with double-blinded investigators in the Kharazmi University, Tehran, Iran. This study was assessed and approved by the Research Ethics Committees of the Sport Sciences Research Institute (Approval ID: IR.SSRC.REC.1401.048) prior to data collection. The study was registered prospectively on Clinical Trials (IRCT20220804055617N1, Registration Date: 17/12/2022, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.irct.ir\u003c/span\u003e\u003cspan address=\"http://www.irct.ir\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The study will performed in accordance with the ethical standards in the World Medical Association Declaration of Helsinki [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eParticipants who met the following inclusion criteria will be considered eligible for the study: male and female flight attendants with non-specific chronic LBP between 20 and 40 years old; LBP onset\u0026thinsp;\u0026ge;\u0026thinsp;6 months; Numeric rating scale score of LBP\u0026thinsp;\u0026ge;\u0026thinsp;5 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Participants will be excluded due to the following conditions: history of any surgery and inflammatory diseases in the spine area, diagnosis of a serious disease that may cause LBP (e.g., acute fracture, spinal dislocation), history of any musculoskeletal abnormalities in the spine area, progressive neurological defects or severe neurological symptoms (e.g., fibromyalgia and rheumatic arthritis) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Randomization","content":"\u003cp\u003eUsing random permuted blocks randomization (16 blocks with size 8), four treatment combinations are independently allocated (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) to participants by 1:1:1:1 ratio (after the initial assessment). The random sequence list was generated by computer (Pocock SJ. Clinical Trials: A Practical Approach. Wiley; 1983) and using (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.randomizer.org\u003c/span\u003e\u003cspan address=\"https://www.randomizer.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). This step will be guaranteed by a blind assessor. The assessor will be blind to group allocation. Participants will not be blind to the study and grouping; however, they were not aware of which treatment will be considered therapeutic (There is an unavoidable risk of bias in this study where the intervention cannot be blinded to patients). Before the evaluation, the necessary training will be given to the outcome assessor on how to measure the outcomes to prevent any questions and answers between the assessor and the participants.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eIntervention\u003c/h2\u003e \u003cp\u003e \u003cb\u003eResistance exercises along with motor skill exercises group\u003c/b\u003e: people receive resistance exercises along with motor skill exercises. Resistance exercises: It includes exercises for the muscles of the trunk area, which is divided into 3 stages, each stage is gradually more difficult. All patients will begin with Phase 1 exercises. Training will be done three days a week and for eight weeks. 2\u0026ndash;3 sets of 8\u0026ndash;10 repetitions are performed 2\u0026ndash;3 times a week. Motor skills training: will include motor skills training and challenging functional activities that are difficult to perform due to back pain [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eResistance exercises with pain reprocessing group\u003c/b\u003e: participants receive resistance exercises with pain reprocessing. Resistance exercises: include exercises for the muscles of the trunk area, which are divided into 3 phases, each phase is gradually more difficult. All patients will begin with Phase 1 exercises. Exercises will be done three days a week and for eight weeks. 2\u0026ndash;3 sets of 8\u0026ndash;10 repetitions are performed 2\u0026ndash;3 times a week [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Pain reprocessing: involves education aimed at increasing patients' re-perception of primary chronic pain as a false alarm generated by the brain. Pain reprocessing shares concepts and techniques with existing treatments for pain and cognitive behavioral therapy for fear disorder [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipants will complete 8 sessions of 1-hour individual therapy sessions with an experienced therapist twice weekly for 4 weeks. Techniques include (1) providing personal evidence for focused pain (2) guided reappraisal of pain sensation while sitting and while engaging in fearful situations or movements (3) techniques focusing on psychosocial factors (e.g., depression) that potentially increase pain, and (4) techniques to increase positive emotions and self-compassion.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResistance exercises with motor skill exercises and pain reprocessing group\u003c/b\u003e: participants receive resistance exercises with motor skill exercises and pain reprocessing. Resistance exercises: include exercises for the muscles of the trunk area, which are divided into 3 phases, each phase is gradually more difficult. All patients will begin with Phase 1 exercises. Exercises will be done three days a week and for eight weeks. 2\u0026ndash;3 sets of 8\u0026ndash;10 repetitions are performed 2\u0026ndash;3 times a week. Motor skills training: will include motor skills education and challenging functional activities that are difficult to perform due to LBP [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePain reprocessing: involves education aimed at increasing patients' re-perception of primary chronic pain as a false alarm generated by the brain. Pain reprocessing shares concepts and techniques with existing treatments for pain and cognitive behavioral therapy for the fear disorder. Participants will complete 8 sessions of 1-hour individual therapy sessions with an experienced therapist twice weekly for 4 weeks. Techniques include (1) providing personal evidence for focused pain (2) guided reappraisal of pain sensation while sitting and while engaging in fearful situations or movements (3) techniques focusing on psychosocial factors (e.g., depression) that potentially increase pain, and (4) techniques to increase positive emotions and self-compassion [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eResistance training group\u003c/b\u003e: Individuals will only receive resistance training. Resistance exercises: includes exercises for the muscles of the trunk area, which is divided into 3 stages, each stage is gradually more difficult. All patients will begin with Phase 1 exercises. Training will be done three days a week and in eight weeks. 2\u0026ndash;3 sets of 8\u0026ndash;10 repetitions are performed 2\u0026ndash;3 times a week [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eMain outcome variables\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003ePrimary outcomes\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section4\"\u003e \u003ch2\u003ePain\u003c/h2\u003e \u003cp\u003eThe Visual Analogue Scale (VAS) will be used to evaluate patients\u0026rsquo; current pain intensity, where 0 signified no pain and 10 signified the worst imaginable pain [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The minimal clinically important difference (MCID) of 2 points has been reported for the LBP [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eSecondary outcomes\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section4\"\u003e \u003ch2\u003eQuality Of Life\u003c/h2\u003e \u003cp\u003eQuality of life will be assessed using the Persian version of the self-reported Short-Form (36) Health Survey (SF-36) (minimum score\u0026thinsp;=\u0026thinsp;0, total maximum score\u0026thinsp;=\u0026thinsp;100, with a higher score indicating better quality of life) with physical and mental component scores also calculated. The SF-36 is a validated multipurpose, short-form health survey with 36 questions and is the most widely used [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDisability\u003c/h2\u003e \u003cp\u003eDisability will be assessed using the Persian version of the Roland\u0026ndash;Morris disability questionnaire (RMDQ). The RMDQ consists of 24 statements about activity limitations due to back pain, e.g., walking, lying, and self-care. The RMDQ overall score ranges from 0 to 24 points, and a higher score represents more severe disability. It is suggested that the MCID of improvement of the RMDQ is 4, which would be clinically meaningful in LBP patients [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eFear of movement\u003c/h2\u003e \u003cp\u003eFear-avoidance beliefs will be measured with the Persian version of the 16-item Fear-Avoidance Beliefs Questionnaire (FABQ). Higher aggregate scores indicate stronger fear-avoidance beliefs. Two subscales within the FABQ are work (seven-question FABQ-W, scores 0\u0026ndash;42), and physical activity (four-question FABQPA, scores 0\u0026ndash;24). FABQ-W assesses the fear of losing work because of pain, and the FABQ-PA assesses the relationship between physical activity and pain exacerbation [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A change of 4 points for FABQ-PA and 7 points for FABQ-W were recommended as MCID [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePain Catastrophizing\u003c/h2\u003e \u003cp\u003ePain catastrophizing will be measured using a Persian version of the Pain Catastrophizing Scale, which consists of 13 descriptions of pain experience [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Each item is rated according to the respondent\u0026rsquo;s perceived thoughts and feelings while experiencing pain. The total score ranges from 0 to 52, with higher scores indicating more catastrophic thoughts [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePain Self-Efficacy\u003c/h2\u003e \u003cp\u003ePain self-efficacy will measure with the Persian version of Pain Self-efficacy Questionnaire (PSEQ), which consists of 10 items scored on a 7-point Likert scale (0\u0026ndash;6 points). Scores range from 0 to 60, with the higher scores indicating stronger self-efficacy beliefs [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The MCID for clinical relevance in this study is considered to be 9 points [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eDepression, Anxiety, Stress\u003c/h2\u003e \u003cp\u003eThe Persian version of the Depression Anxiety Stress Scale (DASS) is a low-cost, easy-to-use scale which allows for a rapid assessment of depression, anxiety, and stress. The items of the scale are rated on a 4-point Likert scale, with the score for each item ranging from 0 (does not apply to me at all) to 3 (applies to me most of the time). The subscale scores were calculated by summing the scores of the individual items and the maximum sum for each subscale is 21; a higher score indicates a worse emotional condition [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. A minimum of 5 points change is recommended to achieve MCID of DASS in patients with LBP [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eThe fingertip-to-floor test (flexion ROM)\u003c/h2\u003e \u003cp\u003eThe patient will stand erect on a 20 cm-high platform with shoes removed and feet together. The patient was asked to bend forward as far as possible while maintaining the knees, arms, and fingers fully extended. The vertical distance between the tip of the middle finger and the platform was measured in centimetres (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSingle Limb Stance\u003c/h2\u003e \u003cp\u003eThe single-leg stance test [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] will be used to assess static postural and balance control. Perform with eyes open and hands on the hips. The patient will be asked to flex one hip between 60 and 90 and maintain this position for 30 seconds. The patient stands on one leg unassisted; time begins when the opposite foot leaves the ground; time stops immediately when the opposite foot touches the ground and/or when hands leave the hips (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSitting On Bobath Ball\u003c/h2\u003e \u003cp\u003eThe patient will sit on a Bobath ball one metre in front of a checked curtain so that one of the longitudinal lines of the curtain was in line with the spine. The raters will be positioned about two metres behind the patient, as close to the patient\u0026rsquo;s midline as possible. The raters will be kneeling down so that the eyes of the raters are in a horizontal line with the patient's lower back. The diameter of the ball will be 65 cm. However, for patients shorter than 160 cm, a ball 55 cm in diameter will used and for patients taller than 190 cm, the diameter of the ball will be 75 cm. The dorsal sides of the patient's hands will be loosely placed on his/her thighs. There will be approximately 5 cm between the feet, and the calves will not touch the ball. The patient will then be asked to lift his/her foot and keep it about 5 cm above the floor for 20 seconds (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The test will be evaluated as negative if the spine will keep in its original vertical position for 20 seconds and if no compensatory movements will be made by the lifted leg or by the arms. A short change from the starting position will accept as long as this position is quickly resumed. Positive if: the spine deviates from the original vertical position and/or compensatory movements will be made by the lifted leg or by the arms and/or two or more short changes from the starting position. Not valid if the patient did not manage to perform the test due to pain [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eMuscular Endurance\u003c/h2\u003e \u003cp\u003eThe torso muscular endurance will be assessed by using the McGill Core Endurance Tests [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The flexor endurance test is the first in the battery of three tests (trunk flexor endurance, trunk lateral endurance, and trunk extensor endurance tests) that assess the muscular endurance of the core muscles (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). It is a timed test involving a static, isometric contraction of the anterior muscles, stabilizing the spine until the individual exhibits fatigue and can no longer hold the assumed position. All the McGill Core Endurance Tests will be explained to patients first, and then the tests will be performed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eData collection and statistical analysis\u003c/h2\u003e \u003cp\u003eAn analysis using G*Power (3.1.9.2, Dusseldorf, Germany) concludes that sufficient power (0.8) is achieved with the primary outcome variable [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], estimated sample size of 60 participants, alpha of 0.05, and estimated effect size (f\u0026thinsp;=\u0026thinsp;0.25).\u003c/p\u003e \u003cp\u003eThe data will be analysed by intention-to-treat (ITT) and by a statistician blinded to group allocation. A mixed linear model will be used to assess the effect of treatment on outcomes and to fit a repeated-measures analysis of variance. Estimates of the effect of the intervention and 95% CI will be estimated by constructing linear contrasts to compare the adjusted difference in means or proportions at each time point between the treatment and control groups. Statistical significance will be set a priori at \u0026le;\u0026thinsp;0.05. SPSS V.25.0 will be used to complete data processing and statistical analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eAdverse events and serious adverse events\u003c/h2\u003e \u003cp\u003eIn this study, data on adverse events will be collected based on patient reports and investigator observations. In addition, we will analyse the incidence of adverse events, abnormal laboratory parameters, and serious adverse events suspected to be related to the treatment. The causality between the treatment and the adverse events will be assessed using a 6-point scale based on the causality assessment system of the World Health Organisation-Uppsala Monitoring Centre.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eMonitoring and trial management\u003c/h2\u003e \u003cp\u003eThe Trial Management Group will provide trial oversight and monitor any safety issues that arise.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of this protocol study is to evaluate the effects of resistance exercises with motor skills training and pain reprocessing on pain, performance and psychological factors in flight attendants with LBP.\u003c/p\u003e \u003cp\u003eIdentification of relevant motor control features or a specific response to a movement test can inform specific movements and exercise therapy, with a rapid response for some patients. Other patients may have a presentation complicated by features such as differences in pain processing, experience of intense pain, fear avoidance, and previous experiences that compromise their full participation in physical treatments. These patients may benefit from coordinating physical and medical treatments to fully recover from an episode of LBP and establish a maintenance program and future self-management of LBP episodes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn people with LBP, psychological factors are important predictors for long-term disability, and pain-related fear is often more disabling than the pain itself [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Indeed, it is assumed that fear-avoidance beliefs prevent subjects from regaining normal function by promoting the development of guarded movements and contributing to disability onset and persistence [\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite several studies looking at factors associated with LBP, few intervention studies addressing these factors with adequate sample size have been performed [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This randomized clinical trial will be the first study to evaluate the resistance exercises with motor skills training and pain reprocessing program on pain, performance, and psychological factors in flight attendants with LBP. The results from this study will help researchers and physiotherapists improve clinical outcomes in patients with LBP.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eTrial status\u003c/h2\u003e \u003cp\u003eAt the time of manuscript submission, participants had not yet been recruited. Participant recruitment is expected to start on 20 December 2025 and end on 20 December 2026. Data analysis is planned to start on 20 December 2026.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLBP: Low Back pain\u003c/p\u003e\n\u003cp\u003eVAS: Visual Analogue Scale\u003c/p\u003e\n\u003cp\u003eMCID: Minimal Clinically Important Difference\u003c/p\u003e\n\u003cp\u003eSF-36: Self-reported Short-Form Health Survey\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRMDQ: Roland\u0026ndash;Morris Disability Questionnaire\u003c/p\u003e\n\u003cp\u003eFABQ: Fear-Avoidance Beliefs Questionnaire\u003c/p\u003e\n\u003cp\u003ePSEQ: Pain Self-efficacy Questionnaire\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDASS: Depression Anxiety Stress Scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eITT: Intention-to-treat\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was assessed and approved by the Research Ethics Committees of Sport Sciences Research Institute (Approval ID: IR.SSRC.REC.1401.048) prior to data collection. The study was registered prospectively on Clinical Trials (IRCT20220804055617N1, Registration Date: 17/12/2022, http://www.irct.ir). The study will perform in accordance with the ethical standards in the World Medical Association Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNZ, AL and GR contributed to the original idea, study design and protocol, the conception of the work, conducting the study, revising the drafting and editing of the article. NZ, AL and GR contributed to the conception of the work, wrote, and editing of this article. All authors have read and approved the final version of the manuscript, and agree with the order of presentation of the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003cspan dir=\"RTL\"\u003e\u003cbr\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRau P-LP, Tsao L, Dong L, Liu X, Ma L, Wang J: \u003cstrong\u003eGeneral and passenger-relevant factors of work-related musculoskeletal disorders (WMSDs) among Chinese female flight attendants\u003c/strong\u003e. \u003cem\u003eWork \u003c/em\u003e2020, \u003cstrong\u003e66\u003c/strong\u003e(4):861-869.\u003c/li\u003e\n\u003cli\u003eDeyo RA, Phillips WR: \u003cstrong\u003eLow back pain: a primary care challenge\u003c/strong\u003e. \u003cem\u003eSpine \u003c/em\u003e1996, \u003cstrong\u003e21\u003c/strong\u003e(24):2826-2832.\u003c/li\u003e\n\u003cli\u003eAndersson GB: \u003cstrong\u003eEpidemiological features of chronic low-back pain\u003c/strong\u003e. \u003cem\u003eThe lancet \u003c/em\u003e1999, \u003cstrong\u003e354\u003c/strong\u003e(9178):581-585.\u003c/li\u003e\n\u003cli\u003eHeneweer H, Staes F, Aufdemkampe G, van Rijn M, Vanhees L: \u003cstrong\u003ePhysical activity and low back pain: a systematic review of recent literature\u003c/strong\u003e. \u003cem\u003eEuropean Spine Journal \u003c/em\u003e2011, \u003cstrong\u003e20\u003c/strong\u003e:826-845.\u003c/li\u003e\n\u003cli\u003eWaddell G, Burton AK: \u003cstrong\u003eConcepts of rehabilitation for the management of low back pain\u003c/strong\u003e. \u003cem\u003eBest Practice \u0026amp; Research Clinical Rheumatology \u003c/em\u003e2005, \u003cstrong\u003e19\u003c/strong\u003e(4):655-670.\u003c/li\u003e\n\u003cli\u003eMonticone M, Ferrante S, Rocca B, Baiardi P, Dal Farra F, Foti C: \u003cstrong\u003eEffect of a long-lasting multidisciplinary program on disability and fear-avoidance behaviors in patients with chronic low back pain: results of a randomized controlled trial\u003c/strong\u003e. \u003cem\u003eThe Clinical journal of pain \u003c/em\u003e2013, \u003cstrong\u003e29\u003c/strong\u003e(11):929-938.\u003c/li\u003e\n\u003cli\u003ePincus T, Vlaeyen JW, Kendall NA, Von Korff MR, Kalauokalani DA, Reis S: \u003cstrong\u003eCognitive-behavioral therapy and psychosocial factors in low back pain: directions for the future\u003c/strong\u003e. \u003cem\u003eSpine \u003c/em\u003e2002, \u003cstrong\u003e27\u003c/strong\u003e(5):E133-E138.\u003c/li\u003e\n\u003cli\u003eJohn JN, Ugwu EC, Okezue OC, Ekechukwu END, Mgbeojedo UG, John DO, Ezeukwu AO: \u003cstrong\u003eKinesiophobia and associated factors among patients with chronic non-specific low back pain\u003c/strong\u003e. \u003cem\u003eDisability and Rehabilitation \u003c/em\u003e2023, \u003cstrong\u003e45\u003c/strong\u003e(16):2651-2659.\u003c/li\u003e\n\u003cli\u003eVarallo G, Giusti EM, Scarpina F, Cattivelli R, Capodaglio P, Castelnuovo G: \u003cstrong\u003eThe association of kinesiophobia and pain catastrophizing with pain-related disability and pain intensity in obesity and chronic lower-back pain\u003c/strong\u003e. \u003cem\u003eBrain Sciences \u003c/em\u003e2020, \u003cstrong\u003e11\u003c/strong\u003e(1):11.\u003c/li\u003e\n\u003cli\u003eChou R, Shekelle P: \u003cstrong\u003eWill this patient develop persistent disabling low back pain?\u003c/strong\u003e \u003cem\u003eJama \u003c/em\u003e2010, \u003cstrong\u003e303\u003c/strong\u003e(13):1295-1302.\u003c/li\u003e\n\u003cli\u003eRainville J, Smeets RJ, Bendix T, Tveito TH, Poiraudeau S, Indahl AJ: \u003cstrong\u003eFear-avoidance beliefs and pain avoidance in low back pain\u0026mdash;translating research into clinical practice\u003c/strong\u003e. \u003cem\u003eThe Spine Journal \u003c/em\u003e2011, \u003cstrong\u003e11\u003c/strong\u003e(9):895-903.\u003c/li\u003e\n\u003cli\u003eWoby SR, Watson PJ, Roach NK, Urmston M: \u003cstrong\u003eAdjustment to chronic low back pain\u0026mdash;the relative influence of fear-avoidance beliefs, catastrophizing, and appraisals of control\u003c/strong\u003e. \u003cem\u003eBehaviour research and therapy \u003c/em\u003e2004, \u003cstrong\u003e42\u003c/strong\u003e(7):761-774.\u003c/li\u003e\n\u003cli\u003eElfving B, Andersson T, Grooten WJ: \u003cstrong\u003eLow levels of physical activity in back pain patients are associated with high levels of fear‐avoidance beliefs and pain catastrophizing\u003c/strong\u003e. \u003cem\u003ePhysiotherapy Research International \u003c/em\u003e2007, \u003cstrong\u003e12\u003c/strong\u003e(1):14-24.\u003c/li\u003e\n\u003cli\u003eHides JA, Donelson R, Lee D, Prather H, Sahrmann SA, Hodges PW: \u003cstrong\u003eConvergence and Divergence of Exercise-Based Approaches That Incorporate Motor Control for the Management of Low Back Pain\u003c/strong\u003e. \u003cem\u003eThe Journal of orthopaedic and sports physical therapy \u003c/em\u003e2019, \u003cstrong\u003e49\u003c/strong\u003e(6):437-452.\u003c/li\u003e\n\u003cli\u003evan Dillen LR, Lanier VM, Steger-May K, Wallendorf M, Norton BJ, Civello JM, Czuppon SL, Francois SJ, Roles K, Lang CE: \u003cstrong\u003eEffect of Motor Skill Training in Functional Activities vs Strength and Flexibility Exercise on Function in People With Chronic Low Back Pain: A Randomized Clinical Trial\u003c/strong\u003e. \u003cem\u003eJAMA neurology \u003c/em\u003e2021, \u003cstrong\u003e78\u003c/strong\u003e(4):385-395.\u003c/li\u003e\n\u003cli\u003eAshar YK, Gordon A, Schubiner H, Uipi C, Knight K, Anderson Z, Carlisle J, Polisky L, Geuter S, Flood TF\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eEffect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial\u003c/strong\u003e. \u003cem\u003eJAMA psychiatry \u003c/em\u003e2022, \u003cstrong\u003e79\u003c/strong\u003e(1):13-23.\u003c/li\u003e\n\u003cli\u003eAssociation WM: \u003cstrong\u003eWorld Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects\u003c/strong\u003e. \u003cem\u003eJAMA \u003c/em\u003e2013, \u003cstrong\u003e310\u003c/strong\u003e(20):2191-2194.\u003c/li\u003e\n\u003cli\u003ePark KS, Kim S, Seo JY, Cho H, Lee JY, Lee YJ, Lee J, Kim MJ, Choi YE, Yang CS: \u003cstrong\u003eEffectiveness and safety of pharmacopuncture therapy for chronic low back pain: a protocol for a pragmatic randomized controlled trial\u003c/strong\u003e. \u003cem\u003eJournal of Pain Research \u003c/em\u003e2022:2629-2639.\u003c/li\u003e\n\u003cli\u003eLanier VM, Lang CE, Van Dillen LR: \u003cstrong\u003eMotor skill training in musculoskeletal pain: a case report in chronic low back pain\u003c/strong\u003e. \u003cem\u003eDisability and rehabilitation \u003c/em\u003e2019, \u003cstrong\u003e41\u003c/strong\u003e(17):2071-2079.\u003c/li\u003e\n\u003cli\u003eScrimshaw SV, Maher C: \u003cstrong\u003eResponsiveness of visual analogue and McGill pain scale measures\u003c/strong\u003e. \u003cem\u003eJournal of manipulative and physiological therapeutics \u003c/em\u003e2001, \u003cstrong\u003e24\u003c/strong\u003e(8):501-504.\u003c/li\u003e\n\u003cli\u003eCrossley KM, Bennell KL, Cowan SM, Green S: \u003cstrong\u003eAnalysis of outcome measures for persons with patellofemoral pain: which are reliable and valid?\u003c/strong\u003e \u003cem\u003eArch Phys Med Rehabil \u003c/em\u003e2004, \u003cstrong\u003e85\u003c/strong\u003e(5):815-822.\u003c/li\u003e\n\u003cli\u003ePiva SR, Gil AB, Moore CG, Fitzgerald GK: \u003cstrong\u003eResponsiveness of the activities of daily living scale of the knee outcome survey and numeric pain rating scale in patients with patellofemoral pain\u003c/strong\u003e. \u003cem\u003eJournal of rehabilitation medicine \u003c/em\u003e2009, \u003cstrong\u003e41\u003c/strong\u003e(3):129-135.\u003c/li\u003e\n\u003cli\u003eMontazeri A, Goshtasebi A, Vahdaninia M, Gandek B: \u003cstrong\u003eThe Short Form Health Survey (SF-36): translation and validation study of the Iranian version\u003c/strong\u003e. \u003cem\u003eQuality of life research \u003c/em\u003e2005, \u003cstrong\u003e14\u003c/strong\u003e:875-882.\u003c/li\u003e\n\u003cli\u003eStratford PW, Binkley J, Solomon P, Finch E, Gill C, Moreland J: \u003cstrong\u003eDefining the minimum level of detectable change for the Roland-Morris questionnaire\u003c/strong\u003e. \u003cem\u003ePhysical therapy \u003c/em\u003e1996, \u003cstrong\u003e76\u003c/strong\u003e(4):359-365.\u003c/li\u003e\n\u003cli\u003eWaddell G, Newton M, Henderson I, Somerville D, Main CJ: \u003cstrong\u003eA Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability\u003c/strong\u003e. \u003cem\u003ePain \u003c/em\u003e1993, \u003cstrong\u003e52\u003c/strong\u003e(2):157-168.\u003c/li\u003e\n\u003cli\u003eMonticone M, Frigau L, Vernon H, Rocca B, Giordano A, Simone Vullo S, Mola F, Franchignoni F: \u003cstrong\u003eReliability, responsiveness and minimal clinically important difference of the two Fear Avoidance and Beliefs Questionnaire scales in Italian subjects with chronic low back pain undergoing multidisciplinary rehabilitation\u003c/strong\u003e. \u003cem\u003eEuropean journal of physical and rehabilitation medicine \u003c/em\u003e2020, \u003cstrong\u003e56\u003c/strong\u003e(5):600-606.\u003c/li\u003e\n\u003cli\u003eIbrahim AA, Akindele MO, Kaka B, Mukhtar NB: \u003cstrong\u003eDevelopment of the Hausa version of the Pain Catastrophizing Scale: translation, cross-cultural adaptation and psychometric evaluation in mixed urban and rural patients with chronic low back pain\u003c/strong\u003e. \u003cem\u003eHealth and Quality of Life Outcomes \u003c/em\u003e2021, \u003cstrong\u003e19\u003c/strong\u003e:1-14.\u003c/li\u003e\n\u003cli\u003ePicavet HSJ, Vlaeyen JW, Schouten JS: \u003cstrong\u003ePain catastrophizing and kinesiophobia: predictors of chronic low back pain\u003c/strong\u003e. \u003cem\u003eAmerican journal of epidemiology \u003c/em\u003e2002, \u003cstrong\u003e156\u003c/strong\u003e(11):1028-1034.\u003c/li\u003e\n\u003cli\u003eWertli MM, Eugster R, Held U, Steurer J, Kofmehl R, Weiser S: \u003cstrong\u003eCatastrophizing\u0026mdash;a prognostic factor for outcome in patients with low back pain: a systematic review\u003c/strong\u003e. \u003cem\u003eThe Spine Journal \u003c/em\u003e2014, \u003cstrong\u003e14\u003c/strong\u003e(11):2639-2657.\u003c/li\u003e\n\u003cli\u003eCosta LdCM, Maher CG, McAuley JH, Hancock MJ, Smeets RJ: \u003cstrong\u003eSelf-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain\u003c/strong\u003e. \u003cem\u003eEuropean Journal of Pain \u003c/em\u003e2011, \u003cstrong\u003e15\u003c/strong\u003e(2):213-219.\u003c/li\u003e\n\u003cli\u003eMaughan EF, Lewis JS: \u003cstrong\u003eOutcome measures in chronic low back pain\u003c/strong\u003e. \u003cem\u003eEuropean spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society \u003c/em\u003e2010, \u003cstrong\u003e19\u003c/strong\u003e(9):1484-1494.\u003c/li\u003e\n\u003cli\u003eHenry JD, Crawford JR: \u003cstrong\u003eThe short‐form version of the Depression Anxiety Stress Scales (DASS‐21): Construct validity and normative data in a large non‐clinical sample\u003c/strong\u003e. \u003cem\u003eBritish journal of clinical psychology \u003c/em\u003e2005, \u003cstrong\u003e44\u003c/strong\u003e(2):227-239.\u003c/li\u003e\n\u003cli\u003eTagliaferri SD, Miller CT, Owen PJ, Mitchell UH, Brisby H, Fitzgibbon B, Masse‐Alarie H, Van Oosterwijck J, Belavy DL: \u003cstrong\u003eDomains of chronic low back pain and assessing treatment effectiveness: a clinical perspective\u003c/strong\u003e. \u003cem\u003ePain Practice \u003c/em\u003e2020, \u003cstrong\u003e20\u003c/strong\u003e(2):211-225.\u003c/li\u003e\n\u003cli\u003ePerret C, Poiraudeau S, Fermanian J, Colau MML, Benhamou MAM, Revel M: \u003cstrong\u003eValidity, reliability, and responsiveness of the fingertip-to-floor test\u003c/strong\u003e. \u003cem\u003eArchives of physical medicine and rehabilitation \u003c/em\u003e2001, \u003cstrong\u003e82\u003c/strong\u003e(11):1566-1570.\u003c/li\u003e\n\u003cli\u003ePenney T, Ploughman M, Austin MW, Behm DG, Byrne JM: \u003cstrong\u003eDetermining the activation of gluteus medius and the validity of the single leg stance test in chronic, nonspecific low back pain\u003c/strong\u003e. \u003cem\u003eArchives of physical medicine and rehabilitation \u003c/em\u003e2014, \u003cstrong\u003e95\u003c/strong\u003e(10):1969-1976.\u003c/li\u003e\n\u003cli\u003eTidstrand J, Horneij E: \u003cstrong\u003eInter-rater reliability of three standardized functional tests in patients with low back pain\u003c/strong\u003e. \u003cem\u003eBMC musculoskeletal disorders \u003c/em\u003e2009, \u003cstrong\u003e10\u003c/strong\u003e:1-8.\u003c/li\u003e\n\u003cli\u003eDejanovic A, Cambridge ED, McGill S: \u003cstrong\u003eIsometric torso muscle endurance profiles in adolescents aged 15\u0026ndash;18: Normative values for age and gender differences\u003c/strong\u003e. \u003cem\u003eAnnals of human biology \u003c/em\u003e2014, \u003cstrong\u003e41\u003c/strong\u003e(2):153-158.\u003c/li\u003e\n\u003cli\u003ePardo GB, Girb\u0026eacute;s EL, Roussel NA, Izquierdo TG, Penick VJ, Mart\u0026iacute;n DP: \u003cstrong\u003ePain neurophysiology education and therapeutic exercise for patients with chronic low back pain: a single-blind randomized controlled trial\u003c/strong\u003e. \u003cem\u003eArchives of physical medicine and rehabilitation \u003c/em\u003e2018, \u003cstrong\u003e99\u003c/strong\u003e(2):338-347.\u003c/li\u003e\n\u003cli\u003eVlaeyen JW, Linton SJ: \u003cstrong\u003eFear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art\u003c/strong\u003e. \u003cem\u003ePain \u003c/em\u003e2000, \u003cstrong\u003e85\u003c/strong\u003e(3):317-332.\u003c/li\u003e\n\u003cli\u003eGrotle M, V\u0026oslash;llestad NK, Brox JI: \u003cstrong\u003eClinical course and impact of fear-avoidance beliefs in low back pain: prospective cohort study of acute and chronic low back pain: II\u003c/strong\u003e. \u003cem\u003eSpine \u003c/em\u003e2006, \u003cstrong\u003e31\u003c/strong\u003e(9):1038-1046.\u003c/li\u003e\n\u003cli\u003eBurke AL, Mathias JL, Denson LA: \u003cstrong\u003ePsychological functioning of people living with chronic pain: A meta‐analytic review\u003c/strong\u003e. \u003cem\u003eBritish Journal of Clinical Psychology \u003c/em\u003e2015, \u003cstrong\u003e54\u003c/strong\u003e(3):345-360.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"disability, muscular endurance, non-specific low back pain, pain, pain neuroscience education, psychological factors","lastPublishedDoi":"10.21203/rs.3.rs-4485068/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4485068/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eLow back pain (LBP) is one of the prevalent chronic pains in flight attendants. Exercise is recommended; however, the effects of resistance exercises with motor skills training and pain reprocessing in flight attendants with LBP are not currently known. This study compares the effect of resistance exercises with motor skills training and pain reprocessing on the pain, performance, and psychological factors of flight attendants with LBP.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study is a randomized controlled trial in which 60 flight attendants with LBP will be enrolled. The patients will be randomly allocated to receive (1) resistance exercises plus motor skill exercises, (2) resistance exercises plus pain reprocessing, (3) resistance exercises plus motor skill exercises and pain reprocessing and (4) resistance training. Participants will be assessed pre- and post-intervention and 3 months after interventions. The primary outcome will be pain intensity. The secondary outcomes will be disability, quality-of-life, fear of movement, pain catastrophizing, pain self-efficacy, depression, anxiety, stress, performance, single-limb stance, sitting on Bobath ball and muscular endurance at post-intervention and 3 months.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eThis study will be the first to compare resistance training with motor skills training and pain reprocessing on pain, performance and psychological factors of flight attendants with LBP. As this research is being conducted in one of the low-income countries, the demographic characteristics and results may differ from those of high-income countries. Results may guide clinicians and improve their clinical outcomes when treating flight attendants with LBP.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eThe protocol was registered prospectively on Clinical Trials (IRCT20220804055617N1, Registration Date: 17/12/2022, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.irct.ir\u003c/span\u003e\u003cspan address=\"http://www.irct.ir\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e","manuscriptTitle":"Effectiveness of the Resistance Exercises with Motor Skills Training and Pain Reprocessing on Pain, Performance, and Psychological Factors in Flight Attendants with Non-Specific Low Back Pain: Study Protocol for a Randomised Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 18:44:40","doi":"10.21203/rs.3.rs-4485068/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9949e7ed-115c-4aaf-966d-66c504568e07","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-18T02:08:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-12 18:44:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4485068","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4485068","identity":"rs-4485068","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}