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Research Report
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onspecific low back pain ery in both the short term and long ferent effects compared with either
(LBP) is a major public health term, but that the improvements were high-load motor control exercises
problem in industrialized soci- small.20 Another study that added spe- potentially stimulating both local
eties, with lifetime prevalence be- cific stabilization exercises to general and global supporting lumbar mus-
tween 60% and 85%.1 Reviews point exercises, however, did not provide cles when performed in neutral
to beneficial effects of supervised any evidence of beneficial effects on spine positions or general exer-
exercises in people with chronic pain and disability.21 According to cises designed for strength (force-
LBP,2,3 but there is no clear evidence Richardson et al,22 the first step in re- generating capacity) and flexibility.
that any specific type of exercise is habilitating motor skill is to train the
better than other forms of exer- patient to cognitively contract the The purpose of this study was to
cise.4 – 6 The term “specific exercise” deep trunk muscles independently. compare supervised low-load (pri-
Randomization and
Interventions
Participants were randomly assigned
to 1 of 3 treatment groups: (1) those
who received low-load, individually
instructed, ultrasound-guided motor
control exercises (MCE group);
(2) those who received high-load, in-
dividually instructed sling exercises
(SE group); or (3) those who received
general exercises (GE group). Eligibil-
ity was assessed by a research physical
therapist, and enrolled patients were
randomly assigned to groups after the
pretreatment assessment. The ran-
domization was administered by an
independent study secretary via tele-
phone. The secretary consecutively re-
ported group allocation for included
participants from a list of random
numbers between 0 and 1 that were
computationally generated. Partici-
pants with numbers in the lower third
of the interval were assigned to the
MCE group, those in the middle third
of the interval were assigned to the SE
group, and those in the upper third of
the interval were assigned to the GE
Figure 1. group. The column of random num-
Exercise interventions in the study: (A) motor control exercises, (B) sling exercises, bers was arbitrarily subdivided into
and (C) general exercises. variable blocks of 3 to 9 to obtain even
distribution of participants in the continuously monitored by direct ob- The supported position where the
groups. servation of respiration and by real- participants could no longer main-
time b-mode ultrasound imaging of su- tain the neutral spine position was
The participants in all treatment perficial and deep muscle activity. used as the baseline for further exer-
groups attended treatment once a Activity in the abdominal muscles was cise progression. By placing the par-
week for 8 weeks. The attendance at visualized on the ultrasound screen for ticipants in demanding but pain-free
weekly treatment sessions was re- each participant and used for feedback positions and asking them to hold
corded, but adherence to home ex- in all treatment sessions. Participants the spine in neutral, the aim was to
ercise was not recorded. All partici- also were instructed in pelvic-floor activate the deep and superficial sta-
pants were encouraged to stay active and multifidus muscle contractions. bilizing trunk muscles (local and
in their daily life, as recommended Furthermore, a goal was to obtain con- global muscles). When weakness,
Table 1.
Characteristics of Participants (n!109) in the 3 Intervention Groups for Background and Outcome Variables at Baselinea
Body mass index, kg/m2 24.9 (3.1) 24.9 (3.1) 24.3 (2.8)
Low back pain, years since first episode, 6.0 (2–19) 9.0 (2–15) 6.0 (3.5–11.5)
NPRS (0–10), present at moment 3.3 (1.3) 3.6 (1.7) 3.3 (1.9)
NPRS (0–10), strongest last month 6.0 (2.0) 6.7 (2.4) 5.9 (1.8)
previous 4 weeks also was recorded Data Analysis Role of the Funding Source
using the NPRS. The Oswestry Dis- This study was part of a larger The Norwegian Fund for Postgradu-
ability Index (ODI), modified ver- project studying the effects of spe- ate Training in Physiotherapy fi-
sion,35 was used to assess disability,36 cific low back exercises on symp- nanced the study. The funding orga-
also termed “self-reported activity lim- toms and underlying neuromuscular nization had no authority over or
itation,” and the total score was ex- mechanisms in which the sample size input into any part of the study. Sling
pressed as a percentage. The Fear- was determined to detect between- exercise equipment was provided
Avoidance Beliefs Questionnaire group changes in feed-forward ac- without obligations by Redcord AS.
(FABQ)37 was used to address nega- tivity in the TrA with an estimated
tive beliefs that can contribute to effect size of 0.8 (unpublished re- Results
prolonged disability.38 The Fingertip- search). We performed an intention- Recruitment and inclusion of par-
to-Floor Test39 was used to examine to-treat analysis, and used mixed linear ticipants were performed between
the participants’ ability to bend for- models to estimate mean scores, to January 2006 and September 2007.
ward in standing by measuring the estimate baseline-adjusted between- After randomization, 36 patients
distance between the longest finger- group differences, and to test whether were allocated to the MCE group, 36
tip and the floor. Lower scores are baseline-adjusted group differences at patients were allocated to the SE
associated with decreased symptoms posttest were significantly different. group, and 37 patients were allo-
for all outcome measures. Participants completing fewer than 6 cated to the GE group (Tab. 1). All
of the 8 treatment sessions were ex- participants were included in the sta-
All outcome measures were applied cluded from postintervention evalua- tistical analyses, independent of
at baseline and after the intervention tion, but their baseline data were in- completion. One physical therapist
period. Although the baseline assess- cluded in the mixed models analysis. performed interventions for all pa-
ment was performed blinded, the The statistical analyses were per- tients allocated to the MCE group.
physical therapist conducting the post- formed with SPSS version 17.0* and The sling exercise and general exer-
intervention evaluation was not NCSS 2007.† The level for statistical cise interventions were led by 4 al-
blinded to treatment group allocation. significance was set at P!.05. ternating physical therapists. In the
At the 1-year follow-up (14 months af- SE group, the therapists instructed
ter randomization), the participants 22, 8, 4, and 2 participants, respec-
answered a questionnaire on pain and tively. In the GE group, the 4 thera-
health care utilization. The person * SPSS Inc, 233 S Wacker Dr, Chicago, IL pists were continuously alternating.
60606.
who analyzed the data was blinded to †
NCSS, 329 North 1000 East, Kaysville, UT Twelve of 80 participants who were
group assignment. 84037. recruited by announcement at the
Excluded (n=11)
Not meeting inclusion criteria (n=10)
▼
Declined to participate (n=1)
▼
Randomized (n=109)
Allocation
▼ ▼ ▼
7 treatment nonadherence
1 treatment nonadherence 3 withdrawals from the study
3 lost to follow-up
4 lost to follow-up 3 lost to follow-up
1 withdrawal from the study
8 weeks (n=31 [86%]) 8 weeks (n=30 [83%])
8 weeks (n=26 [70%])
1 year (n=30 [83%]) 1 year (n=34 [94%])
1 year (n=33 [89%])
▼ ▼ ▼
Analysis
Figure 2.
Enrollment of patients and completion of study.
local hospital and 10 of 29 partici- ried out as planned and are de- group compared with the GE group,
pants who were recruited from pri- scribed in the “Method” section. and 1.0 ("0.1 to 2.0) in the MCE
mary care dropped out during the group compared with the GE group
intervention period. Reasons for Postintervention and (P!.19 for overall group difference,
dropouts during the intervention pe- 1-Year Follow-up Assessments Tab. 2). At the 1-year follow-up as-
riod are shown in Figure 2. At the No significant differences were found sessment, group differences in mean
1-year follow-up assessment, 2 peo- among the groups at the postinterven- current pain adjusted for baseline
ple in the MCE and GE groups each tion assessment for pain, activity limi- score were 0.4 ("0.7 to 1.4) in the
and 1 person in the SE group did not tation (ODI), the FTF, fear-avoidance MCE group compared with the SE
return the questionnaire. The people beliefs for physical activity, or fear- group, 0.3 ("0.8 to 1.4) in the SE
who dropped out were compared avoidance beliefs for work (Tab. 2, group compared with the GE group,
with those who completed the study Fig. 3). Mean current pain group dif- and 0.7 ("0.3 to 1.7) in the MCE
for initial score on background and ferences (95% confidence interval) group compared with the GE group
outcome variables at baseline, and after intervention, adjusted for base- (P!.42 for overall group difference).
no significant differences were line score, were 0.3 ("0.7 to 1.3) in Mean adjusted group differences in ac-
found, as indirectly evident in Tables the MCE group compared with the tivity limitation score (ODI) after inter-
1 and 2. The interventions were car- SE group, 0.7 ("0.6 to 2.0) in the SE vention were 0.6 ("4.3 to 5.4) in the
Table 2.
Estimated Mean (SD) Unadjusted Scores for the Different Treatment Groups and Times and Estimated Mean (95% Confidence
Interval) Baseline-Adjusted Group Differences After Intervention as Given by the Mixed Linear Modelsa
Mean Outcome Adjusted Mean Group Differenceb
MCE Group SE Group GE Group MCE Group vs SE Group vs MCE Group vs
Variable (n!36) (n!36) (n!37) SE Group GE Group GE Group Pc
d
Pain
Current
2 mo 1.76 (1.54) 2.34 (2.26) 2.73 (2.32) 0.27 ("0.73 to 1.27) 0.71 ("0.55 to 1.97) 0.97 ("0.08 to 2.03) .19
Strongest
2 mo 4.09 (2.08) 4.80 (2.41) 5.26 (2.74) 0.57 ("0.57 to 1.71) 0.63 ("0.74 to 2.01) 1.20 ("0.03 to 2.44) .15
e
Disability
2 mo 12.78 (7.62) 16.18 (10.88) 17.75 (9.63) 0.56 ("4.25 to 5.37) 3.02 ("2.44 to 8.47) 3.58 ("0.47 to 7.63) .21
Trunk flexionf
2 mo 7.44 (10.86) 11.13 (10.86) 7.57 (10.86) 0.6 ("3.2 to 4.4) 2.7 ("1.3 to 6.6) 3.3 ("0.7 to 7.3) .23
FABQ, physical
activityg
2 mo 7.31 (4.22) 6.76 (5.37) 8.60 (5.14) "1.58 ("4.00 to 0.84) 1.40 ("1.25 to 4.05) "0.18 ("2.42 to 2.07) .41
h
FABQ, work
2 mo 11.86 (9.67) 12.72 (9.46) 12.44 (8.80) "0.40 ("3.81 to 3.01) 0.65 ("2.70 to 4.00) 0.25 ("2.74 to 3.24) .93
a
MCE group received low-load motor control exercises, SE group received high-load sling exercises, and GE group received general exercises.
b
Group-wise comparison of estimated mean posttest scores adjusted for baseline, contrast estimates. Positive value indicates greater improvement in first
group.
c
Overall between-groups difference in score after intervention, adjusted for baseline. The P values refer to F tests of whether estimated group differences
were significantly different from zero.
d
Pain as assessed with the Numeric Pain Rating Scale. Score range: 0 (“no pain”) to 10 (“worst imaginable pain”). Strongest pain indicates worst pain
experienced during the last 4 weeks.
e
Disability as assessed with the Oswestry Disability Index. Score range: 0 (no activity limitation) to 100 (full activity limitation) for the 10 functions screened.
f
Trunk flexion as assessed with the Fingertip-to-Floor Test (in centimeters).
g
Fear-Avoidance Beliefs Questionnaire for physical activity. Score range: 0 (no fear) to 24 (maximum fear).
h
Fear-Avoidance Beliefs Questionnaire for work. Score range: 0 (no fear) to 42 (maximum fear).
MCE group compared with the SE LBP the year after intervention. One cent) change in ODI score40 and a
group, 3.0 ("2.4 to 8.5) in the SE participant in the SE group reported 2-point change in NPRS score (0 –10)
group compared with the GE group, adverse effects of the intervention and have been suggested as minimum im-
and 3.6 ("0.5 to 7.6) in MCE group withdrew from the study. portant changes for patients25,40,41
compared with the GE group (P!.21 and have been interpreted to repre-
for overall group difference). Discussion sent clinically relevant between-group
This study compared motor control differences.3 The observed mean ef-
Of the participants, 48% in the MCE exercises, sling exercises, and general fects in this study did not reach these
group, 41% in the SE group, and 50% exercises in the early phase of rehabil- levels. However, we cannot exclude
in the GE group sought therapy for itation for patients with chronic non- that motor control exercises are favor-
LBP the year after intervention specific LBP. A course of 8 treat- able for reducing pain relative to gen-
(Tab. 3), and 24% in the MCE group, ments did not show any overall eral exercises because the clinically
31% in the SE group, and 42% in the group effects in pain, disability, and important difference for pain40 was
GE group used medication because of fear-avoidance beliefs. A 10-unit (per- included in the confidence interval
Table 3.
Health Care Utilization Before, During, and After (Follow-up Period) the Interventiona
(Tab. 2). The results from this study who were recruited from health care differences in the present study were
gave no evidence of added benefit of providers, there was a difference in larger for pain and smaller for disabil-
specific exercises over general exer- dropout rate (15% versus 40%, respec- ity relative to pooled effect sizes in a
cises for people with chronic LBP. tively). This difference might have review on motor control exercises
been due to a greater degree of moti- versus other forms of exercise.4 An
Certain limitations apply to this study. vation among the participants who 8-week program of motor control ex-
Sample size was calculated based on initiated participation themselves. The ercises resulted in better short-term
desired effects on onset of muscle ac- exercise interventions were carried function, reduced pain, and improved
tivity in the TrA (unpublished re- out to reflect clinical practice, which perceived effect relative to general ex-
search). With the reported effect sizes strengthens generalization and inter- ercises.7 Effect sizes (95% confidence
for pain (Tab. 2), the study would have pretation of the results. interval) for pain after 8 weeks and 1
dination were needed to maintain toward that observed in individuals Unsgaard-Tøndel and Ms Fladmark provided
the neutral spine position. No dis- who were healthy by as little as 2 data collection, participants, and clerical
support. Mrs Unsgaard-Tøndel, Mr Salvesen,
cernable difference in absenteeism weeks with motor skill training.51
and Dr Vasseljen provided data analysis. Mrs
was found between a sling exercise Only marginal changes in muscle con- Unsgaard-Tøndel, Ms Fladmark, and Dr Vas-
group and a general exercise group traction properties (abdominal muscle seljen provided consultation (including re-
in the only previous study of sling slide and thickness) during the ADIM view of manuscript before submission).
exercises for people with LBP.46 were observed in participants over the The authors thank the Norwegian Fund for
Women with pelvic girdle pain after intervention period in a separate sub- Post-Graduate Training in Physiotherapy for fi-
pregnancy showed significantly study.52 There is a need to scrutinize nancing the study and the physical therapists
lower pain and improved function links between neural mechanisms and at the Multidisciplinary Back Clinic at St. Olav
University Hospital, Trondheim Physiotherapy
after 20 weeks with a specific exer- symptoms to advance outcome mea- Clinic, and Elixia Fitness Centre, for conducting
7 Ferreira ML, Ferreira PH, Latimer J, et al. 20 Costa LO, Maher CG, Latimer J, et al. Mo- 35 Baker D, Pynsent PB, Fairbank J. The Oswe-
Comparison of general exercise, motor tor control exercise for chronic low back stry Disability Index revised: its reliability,
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22 Richardson CA, Hodges PW, Hides JA.
low-up. Spine (Phila Pa 1976). 2005;30: Therapeutic Exercise for Lumbopelvic 37 Waddell G, Newton M, Henderson I, et al.
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9 Descarreaux M, Normand MC, Laurencelle for the Treatment and Prevention of Low (FABQ) and the role of fear-avoidance be-
L, Dugas C. Evaluation of a specific home Back Pain. Edinburgh, Scotland: Churchill liefs in chronic low back pain and disabil-
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Appendix 1.
Sling Exercises: (A) Bilateral Hip Extension With Unilateral Closed Chain, (B) Unilateral Hip Flexion With Contralateral Closed
Chain, and (C) Unilateral Hip Abduction With Contralateral Closed Chain
Appendix 2.
Description of Interventions
The motor control and sling exercise interventions are both termed “specific stabilizing exercises” in this article.
Appendix 3.
General Exercises: (A) Trunk Extension, (B) Leg Curl, and (C) Arm Extension