INTRODUCTION:

Obesity and being overweight refers to an excessive accumulation of body fat, more than what the body needs physiologically as energy ¹. In recent years, the economic and social progress in Asian countries, including Korea, has brought about a Westernization of diets, exposing many to the risks of obesity^{2, 3}.

The obesity rate of Korean adults is fast increasing. The increase rate of those overweight from 1980 to 2013 was 23% for women and 36% for men aged 20 or older.

During the same period, the rate of overweight men aged younger than 20 increased by 23%, while for men the increase rate was 3% and the number of underweight women younger than 20 increased by 12%. This indicates that compared to women, men are taking in too much nutrition. Even compared to men in other countries, this rate is high, as it is 28% in Japan, 25% in China, and 19% in North Korea.

The preservative treatment for obesity for patients with lower back pain was orthopedic manipulative correction, massage, taping, injections, and physical therapy. Ma ⁴noted that manipulative correction of the segmented part of the spine and a strengthening of the muscles or ligaments, as well as reduction of pain, can be a sustainable and effective treatment method.

Since the mid-1980s, the cause of lower back pain has been seen as a lack of physical strength. The trend since then has been to apply proactive exercise programs to improve physical strength⁵. Strengthening of the lower back muscles is widely used, as it is known to be important as part of physical therapy. Leading preventive exercises for lower back pain are extension exercises and curvature movements. Extension exercises include the McKenzie exercise to strengthen the back muscles⁶, and curvature exercise includes William exercises that strengthen the abdominals⁷. A leading exercise to prevent lower back pain is to do extension and curvature exercises to strengthen the muscles in the lower back.

The McKenzie exercise is effective for chronic lower back pain when dull pain is felt in the legs and the flesh feels like someone else’s, which is a symptom of neurological issues in the muscle. Chronic lower back pain refers to cases where lower back pain continues for three months or more. Applying the McKenzie exercise for 12 weeks to young football players showed an improvement in chronic lower back pain. McKenzie exercise helps with the neurological pain in the lower limbs and is known to be effective when done consistently for three months [8]. The William exercise is effective when the lower back is injured or is experiencing acute pain. It is also effective for chronic lower back pain or neurological pain⁸.

In preceding studies, cardiovascular exercises, such as the McKenzie exercise and William exercise, have been applied to overweight patients. In order to identify the effect of McKenzie/William exercises on the body-fat ratio and pain levels of overweight adults, this study categorized the subjects by age, gender, and job type. For the exercise program, lower back exercise and cardiovascular exercises were carried out together. Running and biking were used for cardiovascular exercises, while for lower back exercises, McKenzie/William exercises were done together. Lower back and cardiovascular exercises were carried out to review the physical changes such as changes in the degree of pain or muscle strength. There are studies that report how various exercise programs for overweight patients with lower back pain had a positive effect on the decrease of body weight and of body fat in the abdomen.^9,10,11As such, this study was conducted to identify the effects of the McKenzie/William exercises on overweight adults in Korea.

2. METHODOLOGY:

2.1. Study subjects:

Male and female adults of normal weight with no neurological, physiological abnormalities, cardiovascular diseases, or metabolism-related diseases, such as diabetes, were selected as subjects; these were ten males and ten females living in the Seoul Metropolitan area. The demographic characteristics of the subjects were as shown in Table 1.

Table 1. Demographic characteristics of study subjects

Sex	Age	Average age	Average height (cm)	Average weight (kg)
Male	20 30 40	25.40 33.30 43.80	176.85 175.05 172.63	27.79 81.89 77.57
	Average	34.17	174.84	82.16
Female	20 30 40	25.00 32.80 42.60	166.77 159.87 160.72	79.27 69.10 65.84
	Average	33.47	162.45	71.40

2.2. Study tools:

A questionnaire was administered for this study. There were three questions on the subjects’ demographic characteristics, 10 questions on in-depth information about health, and 10 questions on the lower back pain levels, making it a total of 25 questions.

2.3. Exercise Program:

This study was conducted by implementing the exercise program for the health of the lower back and weight loss for 12 weeks, three sessions per week.

The exercises consisted of 10 minutes of warm-up, 30 minutes each for the lower back and cardiovascular exercises, and 10 minutes of wrap-up exercise. The warm-up and wrap-up consisted of breathing, rotating the neck, rotating the shoulders, rotating the wrists, and relaxing the core, thighs, and legs. The lower-back exercise consisted of McKenzie/William exercises, limited to ensure that they did not cause pain. Cardiovascular exercise consisted of running and cycling.

Subjects were divided into two groups (A and B) and underwent programs for each day of the week. Group A had the McKenzie exercise and running on Mondays, Wednesdays, and Fridays, while Group B had the William exercise and cycling on Tuesdays, Thursdays, and Saturdays. The groups alternated every other week.

2.3.1. McKenzie exercise program:

The McKenzie extension exercise is a leading example of how to strengthen the extension muscle of the lumbar vertebrae. It reduces the weight on the lumbar vertebrae and the pressure on the intervertebral disc, while easing the tension on the neurological muscle of the lumbar vertebrae. For the extending muscle of the lumbar vertebrae, this strengthens the muscles and endurance, and disrupts the pain. It is recommended when the lower back pain is due to collision between intervertebral discs, degeneration of the back joints of the spine, spondylolisthesis, or degeneration of the lumbar vertebrae. That is, it straightens out the curved lower back with extension exercises.

McKenzie exercise in the narrow sense is an exercise that improves the lordosis of the lumbar vertebrae and the cervical vertebrae, while increasing the elasticity of the muscles and the back ligament of the spine. In the wider sense, McKenzie exercise improves the location of all spine dislocations (not only for lordosis but also for hnp and spondy) and stabilizes the spine and surrounding tissue.

A lordotic curve refers to the spine being curved like the letter S. Lordosis refers to the lumbar vertebrae and cervical vertebrae being curved toward the stomach in the shape of a letter C. If lordosis is excessive, it is referred to as hyperlordosis (B); if it is not curved enough it is referred to as hypolordosis (C). But in general, the term lordosis refers to all symptoms where the curve is abnormal ¹².

McKenzie extension exercise has six postures: maintaining a downward facing posture, stretching the lower back backwards while facing downward, stretching the lower back backward while standing, bending the lower back while lying down, and bending the lower back while sitting

2.3.2. William Exercise Program:

William flexion exercise focuses on flexion and reduces the lordosis of the lumbar vertebrae, to reduce the stress on the joints of the back of the spine, and stretches the spinal muscles and fascia of the lumbar vertebrae. This exercise increases the space between the discs, reduces the pressure on the nerves, and supports the lumbar vertebrae by increasing the pressure of the abdominals.

William exercise has as its goal increased bending of the torso, reduced curvature of the lower back to the front, reduced pressure on the back of the spine, increased abdominal muscles, and extension of the spinal muscles. That is, it is a curvature exercise that straightens the lower back of those who are obese in the abdomen by means of long walking.

William exercise consists of six curvature movements: tilting the hip, lifting the upper body, bending both legs, bending the lower back, stretching the lower back muscles, and squatting. In the initial stages, 3-4 sessions with 5-6 repeats per session are carried out. Once adjusted, 10 sessions are carried out. Depending on the body’s condition, 5-9 sessions per day were carried out. When the body could handle it, the movement was maintained for five seconds, with the sixth movement being carried out only after the other five movements had been carried out. All movements were done as long as no pain was felt. Subjects with strong abdominal muscles supported themselves by placing their hands on their lower back or hip, straightening out their knees and lifting until the coxa reached 90 degrees, to strengthen the curvature muscles in the hip. While being on both hands and knees, one leg was extended by straightening out the knee. This was alternated with the other side. This exercise helps strengthen the muscles in the hamstrings and in the hips, as well as the curvature muscles in the coxa, and vertical extension of the spinal and rectus femoral.

2.3.3. Cardiovascular exercise program:

The cardiovascular exercise program used in this study was developed based on the advice from physical strength management institutions, such as health clubs or fitness centers. The exercise starts with easy movements and at low intensity, in order to reach 60-70% of maximum heart rate (220 – age). The first four weeks had an exercise intensity of 60%; for weeks 5 to 8, the intensity was maintained at 70%. Since there were muscular exercises that immediately followed the cardiovascular exercises, the latter were done for a total of 30 minutes. The frequency was three times per week for 12 weeks. For consistency, two instructors were trained in the developed exercise program for one month during June 2015; they later conducted the program for the subjects. The subjects were divided into a total of six groups with ten males and ten females each from Group A. The instructor carried out exercise programs for three groups by gender.

2.4. Measurement:

2.4.1. Pre-test Measurement:

To prepare for the study, health clubs and fitness centers in the Gangseo-Gu and Yangcheon-Gu districts in Seoul were visited for a one-on-one consultation with participants in the experiment group. These people were male or female adults who were overweight and had lower back pain. The subjects were selected from among those who regularly exercised for their health as well as for reducing abdominal fat and body weight. They were asked to select cycling or running for the cardiovascular exercise, based on their body type, stamina, and physical ability, and were asked to exercise for one hour or more.

To compare the participants’ data before and after the program, the participants’ body-fat ratio and level of pain were measured.

2.4.2. Post-test Measurement:

The personal schedules of the researchers were considered in order to select a convenient schedule for measurement. The subjects were divided into two groups for the exercise program, which was conducted for three months at health clubs or fitness centers in the Gangseo-Gu and Yangcheon-Gu districts in Seoul. Group A did 30 minutes of cycling and 30 minutes of McKenzie exercise on Mondays, Wednesdays, and Fridays, while Group B did running for 30 minutes and William exercise for 30 minutes on Tuesdays, Thursdays and Saturdays.

The body-fat ratio and pain levels (from the first questionnaire on July 20, 2015) were surveyed; based on this data, the second survey was conducted three months later (on October 10, 2015). Obesity rate and body-fat ratios were measured with an empty stomach after McKenzie/William exercises and cardiovascular exercises using the In body 3.0 (Biospace, Korea). To evaluate the degree of obesity, the standard used for adults in the Asia-Pacific region was used ¹³.

2.5. Data Processing:

The data collected were analyzed using SPSS 21.0 for statistical analysis and repeated measurement and variance analysis. The mean and standard deviation were calculated. The values for each variable were analyzed before exercise and after exercise to see if there were any statistically significant differences.

3. RESULTS:

Repeated measurement and variance analysis were conducted to see the differences in body- fat ratio across groups and across different treatment periods.

Table 2. Differences between groups and between different periods of treatment across genders

Gender				Before	After 12 weeks		Total
Male (n = 30)		M±SD		.926±.047	.907±.032		.917±.040
Female (n = 30)		M±SD		.881±.065	.862±.056		.872±.061
Total (n = 60)		M±SD		.903±.061	.884±.051		.894±.056
F	group(A)=13.008^**		term(B)=16.038^***			A×B=.005

^**p < .01,^***p < .001

The results for the mean and standard deviation of the body-fat ratio across genders and across periods were Before (.903±.061) and After (.884±.051), and Male (.917±.040) and Female (.872±.061)as shown in Table 2.

A verification of the differences in the body-fat ratio across genders and treatment periods showed that the interactive effect was F_(1,58)= .005 and had no significant difference at a level of p>.05. A verification of the main effect showed that between groups F_(1,58)= 13.008, with no significant difference at a level of p< .001. During the treatment period, F_(1,58)= 16.038, with a significant difference at the level of p< .001. The body-fat ratio across genders showed that it was higher among males than among females and was lower at 12 weeks after the treatment. The results for males in the experiment group were more significant than for women in the experiment group.

Table 3. Pain levels in the males and females in the two groups before and after

Gender			Before		After 12 weeks		Total
Male (n = 30)		M±SD	4.800±3.717		2.966±2.918		3.883±3.318
Female (n = 30)		M±SD	4.966±3.624		2.633±2.822		3.800±3.223
Total (n = 60)		M±SD	4.883±3.641		2.800±2.851		3.842±3.246
F	group(A)=.011			term(B)=57.467^***		A×B=.828

^***p< .001

The mean and standard deviation of pain levels across genders and treatment periods showed before (4.883±3.641) and After (2.800±2.851), and Male (3.883±3.318) and Female (3.800±3.223)as shown in Table 3. A verification of the differences showed that the interactive effect F(1,58) = .828, with no significant difference at the level of p> .05. A verification of the main effect showed that between groups F(1,58) = .011, with no significant difference at the level of p> .05. Between treatment periods, F(1,58) = 57.467 with a significant difference at the level of p< .001. The pain levels across genders showed that it was higher in males than females and lower 12 weeks after the treatment than before.

3.2. Differences between groups and before and after across age groups:

A repeated measurement and variance analysis were carried out to see how body-fat ratio differed before and after across different age groups

Table 4. Body-fat ratio before and after across different age groups

Age				Before	After 12 weeks		Total
29 or younger (n = 20)		M±SD		.918±.082	.890±.053		.904±.068
30∼39 (n = 20)		M±SD		.899±.051	.883±.058		.891±.055
40 or older (n = 20)		M±SD		.894±.043	.881±.042		.888±.043
Total (n = 60)		M±SD		.903±.061	.884±.051		.894±.056
F	group(A)=.511		term(B)=16.284^***			A×B=.947

^***p< .001

The mean and standard variation of body fat between the groups before and after across different age groups showed before (.903±.061) and after (.884±.051), and 29 or younger (.904±.068), 30-39 years old (.891±.055), and 40 or older (.888±.043) as shown in Table 4. A verification of the difference in body-fat ratio before and after across different age groups showed the interactive effect F(2,57) = .947 with no significant difference at the level of p> .05. A verification of the main effects showed that F (2,57) = .511 with no significant difference at the level of p> .05. Between the treatment periods, F(2,57) = 16.284 with no significant difference at the level of p< .001. Body-fat ratio was highest for those aged 29 or younger, and 12 weeks after treatment was lower than before.

Table 5. Pain levels before and after across different age groups

Age			Before		After 12 weeks		Total
29 or younger (n=20)		M±SD	4.350±2.960		2.500±2.090		3.425±2.525
30∼39 (n=20)		M±SD	4.450±3.886		3.050±3.590		3.750±3.738
40 or older (n=20)		M±SD	5.850±3.977		2.850±2.796		4.350±3.387
Total (n = 60)		M±SD	4.883±3.641		2.800±2.851		3.842±3.246
F	group(A)=.452			term(B)=62.017^***		A×B=3.243^*

^*p< .05,^***p< .001

The mean and average of pain levels before and after across different age groups were Before (4.833±3.641) and After (2.800±2.851), and Age 29 or younger (3.425±2.525), 30-39 years old (3.750±3.738), and 40 or older (4.350±3.387)as shown in Table 5. A verification of the pin levels before and after showed the interactive effect F(2,57) = 3.243 with significant difference at the level of p< .05. A verification of the main effect showed that between groups F(2,57) = .452 with no significant difference at the level of p> .05. Between treatment periods, F(2,57) = 62.017, with significant difference at the level of p< .001. The pain level was highest in those aged 40 or older and was lower after 12 weeks after the treatment than before treatment.

3.3. Differences before and after across different professional categories:

Repeated measurement and variance analysis were conducted to see the results of body-fat ratio before and after across different professional categories.

Table 6. Body-fat ratio before and after across different professional categories

`				Before	After 12 weeks		Total
Office workers (n = 23)		M±SD		.899±.061	.872±.047		.886±.054
Manual laborers (n = 37)		M±SD		.915±.058	.894±.052		.905±.055
Total l(n = 60)		M±SD		.903±.061	.884±.051		.894±.056
F	group(A)=3.117		term(B)=15.617^***			A×B=.140

^***p< .001

The mean and standard deviation of body-fat ratio before and after across different professional categories showed before (.903±.061) and After (.884±.051), and Office workers (.886±.054) and Manual laborers (.905±.055)as shown in Table 6. A verification of the difference in body-fat ratio before and after across different professional categories showed the interactive effect F(1,58) = .140, with no significant difference at the level of p> .05. A verification of the main effect showed that between groups, F(1,58) = 3.117, with no significant difference at the level of p> .05. Between treatment periods, F(1,58) = 15.617, with significant difference at the level of p< .001. The body-fat ratio was higher in office workers than in manual laborers and lower 12 weeks after the treatment than before.

Table 7. Pain levels before and after across different professional categories

`				Before	After12 weeks		Total
Office workers (n = 23)		M±SD		4.703±3.603	2.444±2.708		3.574±3.156
Manual laborers (n = 37)		M±SD		5.030±3.720	3.090±2.972		4.060±3.346
Total (n = 60)		M±SD		4.883±3.641	2.800±2.851		3.842±3.246
F	group(A )= .364		term(B ) = 57.283^***			A×B = .332

^***p< .001

The mean and standard deviation of pain levels before and after across different professional categories were before (4.883±3.641) and After (2.800±2.851), and Office workers (3.574±3.156) and Manual laborers (4.060±3.346)as shown in Table 7. A verification of the pain levels before and after across different professional categories showed that interactive effect was F(1,58) = .332, with no significant difference at the level of p > .05. A verification of the main effects showed that between groups, F(1,58) = .364, with no significant difference at the level of p> .05. Between treatment periods, F(1,58) = 57.283, with significant difference at the level of p < .001. The pain levels were higher in manual laborers than in office workers and lower 12 weeks after the treatment than before.

4. DISCUSSION:

This study was conducted to verify the changes in pain levels after experiments by using overweight adults with a fear of potential lower back pain as subjects. The subjects were categorized by age, gender, and professional type. Preceding studies related to obesity categorized pain into tat caused by body-weight overload and pain in the lower limbs, such as hip joints, lower back pain, hamstring pain, and foot pain. In particular, studies related to lower back pain are the majority ¹⁴.

Obesity and excessive body weight has been recognized as a disease to be treated around the world, starting in 1996¹⁵. Korea, too, saw the obesity rate among those aged 20 or older increase consistently to 31.8% as of 2005¹⁶. Obesity raises the risk of other diseases, such as strokes, diabetes, hypertension, cardiovascular diseases, hyperlipidemia, respiratory diseases, and liver cirrhosis¹⁷. Those overweight also have a higher propensity toward chronic degenerative diseases in the skeletal muscular system, such as joint paints or lower back pain that constrain movement in daily life ¹⁸.

Lower back pain undermines the quality of daily life and one’s ability to carry out tasks. In recent years, regardless of age, the incidence of lower back pain has increased, because of increased inactivity at the desk and more time spent indoors ¹⁹. Changes in lifestyle increase the structural instability in the lower back, leading to more lower back pain.

This study verified the effect of McKenzie exercise, which is a full body extension exercise, and William exercise, which is a curvature exercise, combined with cardiovascular exercises, by using 30 male subjects and 30 female subjects who were overweight and had experienced lower back pain, to see how the exercise programs affected their body-fat ratio and pain levels. The results showed that across genders, age groups, and professional categories, body-fat ratio and pain level both saw a significant reduction. That is, the 12 weeks of McKenzie/William exercises combined with cardiovascular exercises had a positive effect on the body-fat ratio and pain levels in overweight adults. This is in line with the results of Kwon et al. ², who reported McKenzie/ William exercises reducing the lower back pain in patients with chronic lower back pain. In the study by Song ²⁰, too, lower back pain reducing programs that include McKenzie/William exercises had a reducing effect on lower back pain and abdominal obesity. Lower back pain is closely related to reduced muscular strength in the lower back. Therefore, this study, too, sees that the increase in muscular strength in the lower back brought about by McKenzie/William exercises contributed to the reduction of pain.

Jung ²¹ reported that a cardiovascular exercise program that uses the McKenzie/William exercises as the basis increased muscular endurance. This study, too, conducted cardiovascular exercises using cycling with the McKenzie/William exercises as the basis and saw an increase in muscular endurance, leading to lower body-fat ratio. Depending on how the cardiovascular exercises are carried out, the results may differ. Song ²⁰ had adult males and females who were undergoing lower back pain treatment undertake 16 weeks of McKenzie exercises with four sessions or more per week to see if they could reduce body-fat ratio. The result was that the factors for muscular endurance, which are push-ups and sit-ups, and factors for flexibility, which are curvature toward the front and toward the back showed an improvement.

Joo¹² conducted a study on lower back pain and explained that McKenzie exercises are one of the most famous methods for preservative therapy and suggested that McKenzie and William exercises were the most effective postures and exercises for reducing the symptoms in patients. The findings of this study support his claim.

This study sought to see the effect of McKenzie/William exercises on patients with chronic lower back pain. The pain levels decreased significantly in both groups that did the McKenzie/ William exercises and cardiovascular exercises. The reduced pain in the group that underwent McKenzie/William exercises is in line with the result that pain was reduced when self-curvature and extension exercise programs were carried out for the lower back in overweight adults.

5. CONCLUSION AND SUGGESTION:

This study was conducted in order to verify the effect on body-fat ratio and pain levels after the exercise program was carried out on overweight adults, and how the changes varied across different genders, ages, and professional categories. The changes in body-fat ratio and pain levels were recorded before and after the 12-week exercise program. The result was that first, there was a statistically significant difference in body-fat ratio before and after. The body-fat ratio was higher in males than in females and lower 12 weeks after the treatment than before. There was a statistically significant difference in the pain levels before and after, too. The pain levels were lower 12 weeks after the treatment than before. Second, there was a statistically significant difference in the body-fat ratio and pain levels across different age groups, with after-treatment levels being lower than before treatment. Third, there was a statistically significant difference in body-fat ratio and pain levels across different professional categories, with after-treatment levels being lower than before-treatment levels.

This result verifies that McKenzie/William exercises that focus on strengthening of muscles have a positive effect on the muscular strength of the lower back. Therefore, in this study, too, McKenzie/William exercises are considered to have contributed to increased muscular strength in the lower back. In this study, individualized exercises seem to have increased the stability in the lower back, and the resistance exercises increased stability, leading to reduced pain.

6. REFERENCES:

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18. Hahn, Moon-Sikl, Lee, Woo-Chun., and Lee, Choon-Seong. The Association Between Degenerative Arthritis of the Lumbar Spine and Obesity. The Journal of the Korean Orthopaedic Association, 1982, 17(6), pp 1080-1088.

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Received on 23.06.2017 Modified on 15.07.2017

Research J. Pharm. and Tech. 2017; 10(7): 2322-2328.

DOI: 10.5958/0974-360X.2017.00411.5