Dual-Task Core Stabilization Training in Chronic Nonspecific Low Back Pain (DT-CSE)

Participants in this group will perform a six-week supervised core stabilization exercise program combined with concurrent cognitive tasks. The intervention will consist of 18 sessions, three sessions per week, with each session lasting 40 minutes. The exercise program will progress through muscle activation, static stabilization, and dynamic functional stabilization stages. Cognitive tasks will include backward counting, verbal fluency, reverse spelling, and working-memory activities, with progressively increasing difficulty. Participants will be instructed to give equal attention to the motor and cognitive tasks.

Participants will receive 18 supervised individual sessions over six weeks (three sessions per week, 40 minutes per session). Each session includes a 5-minute warm-up, 30 minutes of core stabilization exercises, and a 5-minute cool-down. Exercises progress from deep trunk muscle activation (weeks 1-2) to static stabilization (weeks 3-4) and dynamic functional stabilization (weeks 5-6). Concurrent verbal cognitive tasks increase in difficulty and include backward counting, category naming, verbal fluency, reverse spelling, auditory working-memory tasks, and category switching. Participants are instructed to give equal attention to motor and cognitive tasks. The first session is dedicated to exercise instruction.

Participants in this group will receive the same six-week supervised core stabilization exercise program without concurrent cognitive tasks. The program will consist of 18 sessions, three sessions per week, lasting 40 minutes each. Exercise content, intensity, progression, session duration, and therapist supervision will be identical to the experimental group. The physiotherapist will provide only standard instructions regarding exercise performance, without additional cognitive or attention-demanding tasks.

Participants will receive 18 supervised individual sessions of core stabilization exercises over six weeks (three sessions per week, 40 minutes per session). The exercise program will be identical to that of the dual-task group, progressing through muscle activation, static stabilization, and dynamic functional stabilization stages. No concurrent cognitive tasks will be performed.

Motor dual-task cost will be calculated as [(dual-task TUG time - single-task TUG time) / single-task TUG time] × 100. TUG time will be measured in seconds. During the dual-task condition, participants will count backward by threes while performing the TUG test. Two trials per condition will be averaged. Higher percentages indicate greater deterioration in motor performance under dual-task conditions. The primary comparison will be the post-intervention value adjusted for baseline performance and age stratum.

Cognitive performance will be assessed by counting backward by threes under seated single-task and walking dual-task conditions. The correct response rate will be calculated as correct responses per second. Cognitive dual-task cost (%) = [(single-task correct response rate - dual-task correct response rate) / single-task correct response rate] × 100. Higher values indicate greater cognitive performance deterioration.

Walking speed will be assessed under single-task and cognitive dual-task conditions on a 14-meter walkway, with the central 10 meters timed. During the dual-task condition, participants will count backward by threes. Two trials per condition will be averaged. Walking speed will be expressed in meters per second (m/s), with higher values indicating faster walking.

Static balance will be assessed on the preferred leg with arms crossed over the chest under three conditions: eyes open, eyes open with serial subtraction by threes, and eyes closed. Each trial will be limited to 45 seconds. The better result of two trials will be recorded for each condition. Performance will be expressed in seconds, with longer duration indicating better balance.

Average low back pain intensity during the previous week will be assessed using an 11-point Numerical Rating Scale (NRS), ranging from 0 (no pain) to 10 (worst imaginable pain). Higher scores indicate greater pain intensity. A reduction of at least 2 points or 30% will be considered clinically important.

Low back pain-related disability will be assessed using the validated Turkish version of the Oswestry Disability Index (ODI). Scores will be expressed as percentages from 0% (no disability) to 100% (maximum disability). Higher scores indicate greater disability.