Original articleA tailored exercise program versus general exercise for a subgroup of patients with low back pain and movement control impairment: A randomised controlled trial with one-year follow-up
Introduction
Sixty to eighty percent of the adult population suffers from low back pain (LBP) at some point during life (Airaksinen et al., 2006). A previous episode of back pain is highly predictive of future episodes (Stanton et al., 2008, Kolb et al., 2011). In most cases, according to guidelines, a specific diagnosis is not possible and the complaints are labelled as non-specific low back pain (NSLBP) (Waddell, 1987, Airaksinen et al., 2006).
Evidence shows that exercise in general is an effective treatment for patients with sub-acute or chronic NSLBP (Hayden et al., 2005). Due to the great heterogeneity of this patient group, clinicians and researchers have tried to identify subgroups of NSLBP that respond positively to and benefit most from a specific exercise treatment (Foster et al., 2011, Karayannis et al., 2012). One potential subgroup are patients with movement control impairment (MCI), as classified by O'Sullivan (O'Sullivan, 2005). Patients with MCI present with mechanically induced pain in static postures together with visible movement abnormalities, such as decreased or increased movement of parts of the lumbar spine, or discrepancies in the proportion of hip, leg and spine movements. It is assumed that these movement abnormalities are influenced by current pain, previous pain episodes and the belief that pain provoked by movement is harmful (O'Sullivan, 2005). The classification of MCI is based on the observation of aberrant movements accompanied by postural pain (O'Sullivan, 2005). A further sub-classification of MCI identifies the specific movement direction in which control is reduced (Dankaerts et al., 2006, Dankaerts and O'Sullivan, 2011). The sub-classification categories are flexion, active extension, passive extension, lateral shift or multidirectional MCI (O'Sullivan, 2005). Many MCI test procedures have been developed in recent years, (Sahrmann, 2002, O'Sullivan, 2005, Carlsson and Rasmussen-Barr, 2013). In order to define MCI subgroups more clearly, several tests have been evaluated by Luomajoki with a set of 6 MCI tests showing substantial intra-rater and inter-rater reliability (Luomajoki et al., 2007). MCI tests were shown to effectively distinguish healthy persons from patients with LBP (Luomajoki et al., 2008, Luomajoki et al., 2010).
On the assumption that MCI patients would show better outcomes from treatment targeted at the individual MCI sub-classification, specific exercises were developed that aimed at relearning normal movement patterns (Luomajoki et al., 2010). These exercises were performed with increasing levels of difficulty (Luomajoki, 2010). Patients performed initial, easy, low load exercises, e.g. the positioning of the spine in a neutral position, and progressed to increased load and more complex functional requirements. Finally, unconscious application of the learnt movement patterns in daily activities was trained. These MCI subgroup specific exercises were targeted at the functional movement problems of the individual patient. However, it remains unclear as to whether individually-tailored treatment leads to superior outcomes.
To date, the proposed mechanisms and treatment of local stabilising muscles, such as multifidi and transversus abdominis, have received considerable attention in spinal control research. Two recent meta-analyses measuring pain and disability outcomes compared specific motor control exercises with other forms of exercises but obtained different results. Both papers showed favourable outcomes on both pain and disability for motor control over other forms of exercise in the short and intermediate term. They also agreed that no long term benefit on pain was seen. However, there was disagreement regarding the long term effect on disability (Bystrom et al., 2013, Smith et al., 2014). An RCT assessing the effectiveness of exercises and behavioural treatment for MCI, as proposed by O'Sullivan, showed some evidence of improved disability and pain when compared with manual therapy and exercise (Vibe Fersum et al., 2013). However, the latter study is regarded of moderate quality due to the substantial loss of patients in follow-up and to a lack of intention to treat analysis. Furthermore, the question remains unanswered as to which was responsible for the difference: the exercises or the behavioural approach.
To clarify, which exercise approach is superior for patients in the MCI subgroups, movement control (MC) exercises were compared with general exercises (GE) in this current study. A clearly described general exercise programme was selected for the control group to allow for a realistic treatment option. A previous study, in which patients were not assessed for subgroups, had found a better short term effect on disability in patients with LBP with this exercise regime than lumbar stabilising exercise plus general exercise (Koumantakis et al., 2005).
We studied the effects of specific movement control exercises versus general exercise in a multicentre RCT. This article reports on the results at the six-month and 12 months follow-up and demonstrates the effect on disability and pain of specifically-tailored, active exercise treatment compared with general exercise treatment in patients with NSLBP and MCI.
Section snippets
Trial design
A parallel-group RCT with follow-ups at six months and 12 months was performed in five hospital outpatient departments and eight private practices in Switzerland. Patients were recruited from referring hospitals and resident physicians, as well as through advertising amongst the staff and students of the Zurich University of Applied Sciences, Winterthur, Switzerland (ZHAW). The trial was registered (ISRCTN80064281) and ethical approval obtained from the Swiss Ethics Committee KEK-ZH-NR:
Participants
Between August 2010 and February 2012 a total of 201 patients were evaluated for eligibility. As described in the flow chart (Fig. 1), 48 patients did not meet the primary inclusion criteria. A further 47 patients were excluded from randomisation after baseline assessment. The main reasons for exclusion were minimal disability (<5 RMDQ) or no movement control impairment (<2 MCI tests positive). After signing informed consent, 106 patients were randomised (MC = 52, GE = 54). The final number of
Discussion
The findings of this study indicate no additional benefit on disability and pain to patients with NSLBP and MCI of movement control exercise versus general exercise. Both groups improved significantly on all outcomes over time.
Conclusion
Contrary to our expectation, MC exercise and GE exercise appear equally effective in the patient subgroup included in this study. We can conclude that the contrast between both types of intervention did not bring additional value to the shared effects. Decisions for the application of either active treatment approach can currently not be taken on the basis of the results of this study. It is possible that the type of exercise treatment is less important than previously presumed; that the
Acknowledgements
The authors would like to thank all patients who participated in this study.
We wish to thank physiotherapists and doctors in clinics and practices in Switzerland, which are: Bethesda Spital, Basel; Kantonsspital Winterthur, Winterthur; Klinik, Schulthess, Zurich; Medbase Physiotherapie, Winterthur; Physiotherapie Seen, Winterthur; Physiotherapie Bellaria, Zurich; Physiotherapie Erlenbach, Erlenbach; Physiotherapie Reinach, Reinach; Physiotherapie Würenlingen, Würenlingen; Provital
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2018, Musculoskeletal Science and PracticeCitation Excerpt :Baseline assessment showed a mean disability of 6.1 (scale 0–10, lower score means greater disability) as measured by the Patient-Specific Functional Scale (PSFS) and a score of 9.25 (scale 0–24, higher score means greater disability) on the Roland Morris Disability Questionnaire (RMDQ)(Roland and Morris, 1983; Stratford et al., 1995). Characteristics of the qualitative sample showed no notable differences to the total RCT sample (Saner et al., 2015). Also both groups (MC and GE) were found to be largely similar, with the only difference being sports participation at baseline, with more MC participants reporting “no sport” (MC = 44.5%; GE = 26.9%).
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2018, Musculoskeletal Science and PracticeCitation Excerpt :However, these guidelines do not recommend a specific type of exercise (Airaksinen et al., 2006; Wong et al., 2016), thus clinicians must choose from a range of exercises including, but not limited to, general aerobic, flexibility, strengthening, and motor control exercises (Airaksinen et al., 2006; UK, 2016). While there is the view that subgroups of patients with LBP may benefit from one type of exercise more than another, there is limited evidence to support this approach at the current time (Kent et al., 2010; Saner et al., 2015; Lehtola et al., 2016; Azevedo et al., 2017). In addition to deciding on the type of exercise, clinicians must also consider whether exercise should be performed pain-free or into pain.
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2018, Musculoskeletal Science and PracticeCitation Excerpt :The studies followed different strategies regarding restriction of their samples. While a few of the studies restricted their samples to patients with MVCI (Lehtola et al., 2016; Salamat et al., 2017; Saner et al., 2015; Sheeran et al., 2013; Vibe Fersum et al., 2013), other studies included all patients with non-specific LBP without restriction (Aasa et al., 2015; Henry et al., 2014; Jacobs et al., 2016; Kent et al., 2015; Suni et al., 2006). This fact may have affected the large heterogeneity between the studies.
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Present address: Research Department, Rehabilitation Centre Valens, 7317 Valens, Switzerland.