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Benefit of specific vs general exercise for low back pain with movement control impairment
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September 2016
Benefit of specific vs general exercise for low back pain with movement control impairment
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
Sub-classification based specific movement control exercises are superior to general exercise in sub-acute low back pain when both are combined with manual therapy: A randomized controlled trial
BMC Musculoskelet Disord. 2016 Mar 22;17(1):135Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
70 patients with sub-acute low back pain (LBP) and movement control impairment were randomized to receive either specific movement control exercise or general exercise (control) in combination with manual therapy. The purpose of this study was to determine if there is a significant difference in clinical outcomes between general and specified therapies for improving disability. The findings of this study indicated a significantly greater improvement in disability form baseline, assessed by the Roland-Morris Disability Questionnaire, and significantly less need for pain medications in the specific movement control exercise group compared to the control group after 12 months. Patient-specific functional scale scores demonstrated a significantly greater improvement from baseline values in the specific movement control exercise group compared to the Control group at 12 months, but not at 3 months. The Oswestry Disability Index, need for other treatment methods, the number of absences from work, and patient satisfaction were comparable between groups.
Publication Funding Details
+
Funding:
Not Reported
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Randomization
3/4
Outcome Measurements
4/4
Inclusion / Exclusion
4/4
Therapy Description
4/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Low back pain is a common disorder in the general population that can often lead to disability and a decreased quality of life. The etiology of low back pain varies greatly and frequently results in unidentifiable pain symptoms. It is often recommended that patients with low back pain be divided into sub-groups as guided by the O'Sullivan system to allow for tailored treatment. One such subgroup is movement control impairment, which is characterized by patients that provoke pain through maladaptive physical compensation. While sub-acute low back pain is traditionally managed with exercise regimens, there is limited evidence evaluating the comparative effectiveness of general and specific exercise treatments for low back pain patients with movement control impairment, thus warranting the present study.
What was the principal research question?
In the treatment of sub-acute low back pain with movement control impairment, is there a difference between general and specific exercise therapy when assessed over a 12-month period using pain, function, and disability outcome measures?
Study Characteristics
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Population:
70 patients with low back pain (LBP) between the ages of 16 and 65 years were included in this study. Eligible patients had non-specific LBP for at least 6 weeks, were physically healthy to partake in active exercise, had a score of >4 on the Roland-Morris Disability Questionnaire (RMDQ), <12 on the Finnish validated depression scale, <38 on the Tampa Scale for Kinesiophobia, and <80 on the Motor Control Abilities Questionnaire. All patients participated in five treatment sessions over 3 months of their respective randomized treatments. (61 completed follow-up)
Intervention:
Specific movement control exercise group: Patients participated in a physical therapist-supervised specific movement control exercise regimen in the positions of sitting, four-point kneeling, and standing. The exercise program was structured similar to a general exercise program with 3 sets of 15 repetitions with progressive intensity. Each session lasted for 45 minutes in duration with a 10-15 minute manual therapy session. Home exercises were also prescribed 3 times a week, with sitting, four-point kneeling, and standing exercises to be performed once or twice daily. (n=35; Mean age: 51 +/- 11; 20F/15M; 30 completed follow-up)
Comparison:
Control group: Patients participated in a general exercise regimen for 45 minutes in duration, with an embedded manual therapy session of 10-15 minutes. (n=35; Mean age: 48 +/- 11; 22F/13M; 31 completed follow-up)
Outcomes:
The primary outcome of this study was disability as measured with the Roland-Morris Disability Questionnaire (RMDQ). Secondary outcome measures consisted of the Patient-Specific Functional Scale, the Oswestry Disability Index (ODI), and movement control tests. Quantity of absence from work, need for other treatments, pain medication, and patient satisfaction were also reported using a 1 to 5 point scale.
Methods:
RCT: single-centre
Time:
Outcomes were measured immediately after treatment (3 months) and at 12 month follow-up.
What were the important findings?
- Significantly greater improvement in change from baseline was reported in the specific movement control exercise group compared to the Control group for the Roland-Morris Disability Questionnaire at 3 months (-2.4 [95% CI -4.5, -1.1]; p<0.01) and 12 months (-1.7 [95% CI -3.9, -0.5]; p<0.01)
- Both groups demonstrated a significant improvement from baseline on the Patient-specific functional scale, however, no significant difference in the change from baseline was reported between treatment groups at 3 months (p=0.13). At 12 months a significantly greater improvement in change from baseline was reported in the specific movement control exercise group compared to the Control group (3.1 [95% CI 0.2, 6.0]; p=0.03)
- Both groups significantly improved from baseline on the Oswestry Disability Index; however, no significant differences in change from baseline were reported between treatment groups for the Oswestry Disability Index at 3 months (p=0.35) or at 12 months (p=0.35)
- Pain medication was needed significantly less in the specific movement control exercise group compared to the control group at 12 months
- No significant differences were reported between groups for the number of absences from work, need for other treatments, or patient satisfaction
What should I remember most?
In the treatment of recurring low back pain with movement control impairment, the use of a specific movement control exercise regimen was associated with significantly greater reduction disability scores from baseline and a reduced need for medication when compared to a general exercise regimen at 3 and 12 months. Additionally, a significantly greater improvement from baseline in the patient-specific functional scale was observed in the specific movement control exercise group at 12 months. The Oswestry Disability Index, the number of absence from work, need for other treatment modalities, and patient satisfaction remained similar between groups throughout the study duration.
How will this affect the care of my patients?
The findings of this study suggest that specific movement control exercise in combination with manual therapy may provide a more beneficial outcome compared to general exercise programs for patients with sub-acute LBP and movement control impairment. Future trials should compare the benefits of specific movement control exercise with various other types of general exercise programs to confirm the specific efficacy of this treatment modality in this patient population.
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