Exercícios controle motor e lombalgia

Exercícios controle motor e lombalgia

• 1.
  LITERATURE REVIEW SPINEVolume 38, Number 6, pp E350–E358 ©2013, Lippincott Williams & Wilkins Motor Control Exercises Reduces Pain and Disability in Chronic and Recurrent Low Back Pain A Meta-Analysis Martin Gustaf Byström , RPT, MSc , * Eva Rasmussen-Barr , PhD , * † and Wilhelmus Johannes Andreas Grooten , PhD* ‡ Study Design. Meta-analysis of randomized, controlled trials. Objective. To determine the short-term, intermediate, and long-term effectiveness of MCE, with regard to pain and disability, in patients with chronic and recurrent low-back pain. Summary of Background Data. Previous meta-analyses have shown no difference between the effects of MCE and general exercise in the treatment of low back pain. Several high quality studies on this topic have been published lately, warranting a new meta-analysis. Methods. We searched electronic databases up to October 2011 for randomized controlled trials clearly distinguishing MCE from other treatments. We extracted pain and disability outcomes and converted them to a 0 to 100 scale. We used the RevMan5 (Nordic Cochrane Centre, Copenhagen, Denmark) software to perform pooled analyses to determine the weighted mean differences (WMDs) between MCE and 5 different control interventions. Results. Sixteen studies were included. The pooled results favored MCE compared with general exercise with regard to disability during all time periods (improvement in WMDs ranged from − 4.65 to − 4.86), and with regard to pain in the short and intermediate term (WMDs were − 7.80 and − 6.06, respectively). Compared with spinal manual therapy, MCE was superior with regard to disability during all time periods (the WMDs ranged between − 5.27 and − 6.12), but not with regard to pain. Furthermore, MCE was superior to minimal intervention during all time periods with regard to both pain (the WMDs ranged between − 10.18 and − 13.32) and disability (the WMDs ranged between − 5.62 and − 9.00). Conclusion. In patients with chronic and recurrent low back pain, MCE seem to be superior to several other treatments. More studies are, however, needed to investigate what subgroups of patients experiencing LBP respond best to MCE. Key words: exercise therapy , low back pain , motor control , multifi dus , rehabilitation , stability exercise , transversus. Spine 2013 ;38:E350–E358 Low back pain (LBP) is one of the most common pain complaints, with a lifetime prevalence of between 60% and 80%. 1 Despite this, the etiology of LBP remains largely unknown and the majority of cases do not receive a specifi c diagnosis, giving rise to the term “nonspecifi c LBP.” 1 , 2 One proposed mechanism in the development of LBP is that spinal instability causes injury to structures with embed-ded mechanoreceptors. 3 , 4 Panjabi 3 , 5 hypothesized that spinal stability depends on 3 systems: the passive articular system, an active muscular system, and a neural control system. Bergmark 6 divided the muscular system into a local system, which fi ne controls intervertebral motion, and a global sys-tem, which generates spinal motion. Muscles that have been argued to play a major role in spinal stability are primarily the transversus abdominis (TrA) and the multifi dus, but also the pelvic fl oor and the diaphragm. 6 – 10 Recent research has proposed that the activity of the TrA is associated with pos-tural demand in standing. 11 In individuals with LBP, the local musculature exhibits disturbed motor control patterns and changed physiological properties. 7 , 10 – 17 Motor control exer-cises (MCE) have been devised to correct these defi ciencies and retrain optimal movement patterns and control of spinal motion and are currently being used by physical therapists worldwide in the treatment of LBP. Five systematic reviews on MCE in LBP have been published, 18 – 22 2 of which carried out pooled analyses. 18 , 21 Macedo et al 18 searched the literature up to June 2008 and concluded that MCE is superior to mini-mal intervention, but not to spinal manual therapy or general exercise in subacute, chronic, and recurrent LBP. Since 2008, a number of high quality, randomized controlled trials (RCTs) have been published, warranting an updated pooled analysis. The objective of the present meta-analysis was to investi-gate the short-term, intermediate, and long-term effect of MCE From the * Department of Neurobiology, Division of Physiotherapy Caring Sciences, and Society, Karolinska Institute, Huddinge, Sweden ; † Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden ; and ‡ Department of Health Sciences, Division of Occupational and Environmental Medicine, Karolinska Institute, Stockholm, Sweden . Acknowledgment date: August 23, 2012. Revision date: December 10, 2012. Acceptance date: December 11, 2012. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No relevant fi nancial activities outside the submitted work. Address correspondence and reprint requests to Eva Rasmussen-Barr, PhD, Karolinska Institute, Division of Physiotherapy, Department of Neurobiology, Caring Sciences, and Society, 23 100, S-141 76 Huddinge, Sweden; E-mail: [email protected] DOI: 10.1097/BRS.0b013e31828435fb E350 www.spinejournal.com March 2013 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
• 2.
  LITERATURE REVIEW MotorControl Exercise Reduces Pain and Disability in LBP • Byström et al with regard to pain and disability in patients with chronic and recurrent LBP. MATERIALS AND METHODS Criteria for Inclusion We included RCTs reported in English and available online, and including participants at least 16 years of age classifi ed as having chronic or recurrent LBP. We also included stud-ies containing some subacute patients if the average duration exceeded 6 months or if more than 80% of the participants had chronic LBP. In this study, “chronic” denotes a duration of more than 12 weeks 1 and “recurrent LBP” is defi ned as pain recurring after a pain-free interval. 23 “Acute” denotes a duration of 0 to 3 weeks and “subacute” is used to mean 4 to 12 weeks. 1 The study design had to include at least one intervention arm with MCE, that is, with the intervention labeled as MCE, segmental stabilizing exercise, or specifi c sta-bilizing exercise. The intervention was also considered MCE if it included exercises described as “abdominal hollowing” or “abdominal draw-in” or if it was stated that the initial stage aimed to isolate isometric contraction of the TrA and/or the MF. Only RCTs with a clear contrast between MCE and other treatments were included in the study, as recommended by the Cochrane Back Review Group. For example; studies investi-gating a combination of MCE and spinal manual therapy had to include a control group treated with only spinal manual therapy. The follow-up period had to be at least 6 weeks, and outcome measures had to include pain and/or disability. Finally, the outcomes had to be reported on a continuous scale, giving either the mean change from baseline and corresponding stan-dard deviation (SD) or data that allowed calculation of these values, such as quartiles or standard errors. We excluded stud-ies whose participants had undergone back surgery during the year prior to the intervention start, or experienced rheumatoid arthritis, osteoporosis, fractures, malignancies, or any kind of systematic diseases or nonmechanical LBP, or were pregnant/ experienced postnatal-related LBP. Identifi cation and Selection of Studies A systematic search for relevant studies was performed up to October 2011 in the PubMed, EMBASE, PEDro, and CINAHL databases, as recommended by the Cochrane Back Review Group. 24 The following search path was used: (low back pain) AND (segmental OR stabili* OR multifi dus OR transversus OR core OR (motor control). Limits: RTC, human trials, written in English. Two reviewers examined the titles and selected relevant studies. The abstracts of the remaining studies were then reviewed and more studies were excluded. Finally, the remain-ing studies were investigated in full length and a fi nal selection of studies was made. The second reviewer was blinded to the authors of the studies when making the selection. Methodological Quality Assessment The 10-point PEDro scale was used to determine the quality of the included studies to identify high-quality ( ≥ 6 points) and low-quality ( < 6 points) studies. 25 , 26 All included studies had already been rated by raters of the PEDro database. The quality assessment was not used to exclude studies. Data Extraction and Analysis The included studies were sorted into the following categories: 1. MCE versus general exercise. 2. MCE versus spinal manual therapy. 3. MCE versus minimal intervention. 4. MCE versus multimodal physical therapy. 5. MCE as part of a multimodal intervention versus the other components of that intervention. Three follow-up time periods were considered: a short-term: 6 weeks or more and less than 4 months; intermediate-term: 4 or more and less than 8 months; and long-term period: 8 months or more and less than 15 months. If one study reported outcomes at multiple time points within the same time period, the outcome closest to 3 months, 6 months, and 12 months was considered. General exercise constituted any exercise other than MCE. Similar categories have been used in previous reviews. 18 , 22 “Minimal intervention” is defi ned here as no inter-vention, or as advice/education or placebo treatment. Pain and disability scores were transformed to a common 0 to 100 point scale. The RevMan5 (Nordic Cochrane Centre, Copenhagen, Denmark) software was used to calculate the weighted mean difference (WMD) between the index and the control intervention and the 95% confi dence interval (CI). 27 RevMan5 requires data to be entered as the within-group mean change from baseline and the change from baseline SD. For stud-ies only reporting the mean and SD at baseline and follow-up, we calculated the change from baseline SD using Equation 1. SDchange = √SD2 baseline + SD2 follow-up − (2 × Coerr × SDbaseline × SDfollow-up) (1) In the equation, a conservative value of coerr = 0.5 was used; a lower value implies that an analysis based solely on the outcome at follow-up is more precise than a change from baseline analysis. 28 For studies reporting medians and quar-tiles, the SD was calculated using Equation 2. 28 SD = Quartile range 1.35 (2) Pooled analyses were carried out using the RevMan5 soft-ware, which uses the inverse variance method. 27 , 29 We used a random effects model when the data displayed statistical heterogeneity; for homogenous data, we used a fi xed effects model. 27 , 28 To determine the statistical heterogeneity, Rev- Man5 calculates the statistic I, 2 which is an approximate mea-sure of the proportion of the variation due to heterogeneity rather than sampling error. 29 A value of I 2 50% or more is considered substantial heterogeneity. 28 RESULTS The systematic search retrieved 117 studies from PubMed, 107 from EMBASE, 72 from PEDro, and 21 from Spine www.spinejournal.com E351 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
• 3.
  LITERATURE REVIEW MotorControl Exercise Reduces Pain and Disability in LBP • Byström et al CINAHL. After removing duplicative studies, a total of 184 studies remained. Of these, 117 were excluded on the basis of their title, 6 were not written in English, and 2 were not available online. We excluded another 43 stud-ies after reviewing their abstracts or full text. Seventeen of these were excluded because they did not report relevant outcomes. Nine were excluded because the intervention did not constitute MCE. Seven were pilot studies or descrip-tions of study designs and not RCTs. The remaining studies were excluded for the following reasons: 3 studies did not provide a clear contrast, 3 studies included subjects with-out LBP, 2 studies included subjects with acute LBP, 1 study included subjects who had undergone surgery, and the follow-up period of one study was too short. The system-atic search, therefore, resulted in a total of 16 included studies ( Tables 1 – 5 ). The methodological quality of the included studies varied from 4 to 9 points on the PEDro scale, with an average of 6.4. Ten studies were of high qual-ity and 6 were of low quality. Motor Control Exercise Versus General Exercise Seven studies compared effects of MCE to effects of general exercise. 30 – 36 One of these 30 provided comparisons with 2 dif-ferent types of general exercise, sling exercise, and a combi-nation of general strengthening and stretching. Consequently, 8 comparisons were included in this category ( Table 1 ). The pooled results favored MCE with regard to pain in the short (WMD, − 7.80; CI, − 10.95 to − 4.65) and intermediate term (WMD, − 6.06; CI, − 10.94 to − 1.18) and also with regard to disability in the short (WMD, − 4.65; CI, − 6.20 to − 3.11), TABLE 1. Trials Comparing Motor Control Exercise With General Exercise Study PEDro Scale Participants Intervention Outcome/ Follow-up Unsgaard-Tondel et al 30 7/10, high quality N = 109. Male and female, 19–60 (mean, 40.1) yr. LBP ≥ 3 mo. (1) MCE. (2) GE: sling exercise. One session/wk for 8 wk. Pain (NRS), 8 wk and 1 yr; disability (ODI), 8 wk Unsgaard-Tondel et al 30 7/10, high quality N = 109. Male and female 19– 60 (mean, 40.1) yr. LBP ≥ 3 mo. (1) MCE. (2) GE: trunk strengthening and stretching. 1 session/wk for 8 wk. Pain (NRS), 8 wk and 1 yr; disability (ODI), 8 wk Franca et al 31 7/10, high quality N = 30. Male and female, mean, 41.9 yr. LBP > 3 mo. (1) MCE. (2) GE: trunk strengthening. 12 sessions during 6 wk. Home exercise was discouraged. Pain (VAS, MPQ); disability (ODI), 6 wk Rasmussen- Barr et al 32 7/10, high quality N = 71. Male and female, 18–60 (mean, 38.5) yr. Recurrent LBP ( > 8 wk), average duration, 10 yr. (1) MCE. 1 session with PT every week for 8 wk, daily home training. (2) Instruction to take 30-min walks daily, general home exercises. 8 wk, meeting the PT 2 times (wk 1 and 8). Disability (ODI); pain (VAS), 8 wk; 6, 12, and 36 mo Akbari et al 33 5/10 low quality N = 49. 18–80 (mean, 39.8) yr. LBP ≥ 3 mo. Suitable for MCE (unable to contract TrA/MF correctly). (1) MCE. 2. GE: trunk strengthening. Both groups performed 16 sessions during 8 wk. Pain (VAS); disability (BPS), 8 wk Critchley et al 34 7/10, high quality N = 212. Male and female, ≥ 18 (mean, 44) yr. LBP ≥ 12 wk. (1) MCE, individual PT followed by group exercises. Max 8 sessions, 90 min/session. (2) GE (strength and cardiovascular), stretching, education. Max 8 sessions, 90 min/session. Disability (RMDQ); pain (0–100), 6, 12, and 18 mo Ferreira et al 35 8/10, high quality N = 240. Male and female, 18–80 (mean, 53.6) yr. LBP ≥ 3 mo. (1) MCE. (2) GE (strength and cardiovascular), stretching. Up to 12 sessions during 8 wk. Daily home exercise encouraged. Pain (VAS); disability (RMDQ), 8 wk; 6, and 12 mo Miller et al 36 5/10, low quality N = 30. Male and female, 19–87 (mean 49) yr. LBP ≥ 7 wk, mean duration 26 mo. (1) MCE. (2) McKenzie (with SMT for some patients) during 6 wk, schedule determined by PT and patient. Home exercises prescribed. Pain (SF-MPQ); disability (FSQ), 6 wk BPS indicates back performance scale; FSQ, functional status questionnaire; GE, general exercise; LBP, low back pain; MCE, motor control exercise; mODI, modifi ed Oswestry disability index; MPQ, McGill pain questionnaire; NRS, numerical rating scale; ODI, Oswestry low back pain disability questionnaire; PT, physiotherapist or physiotherapy; RMDQ, Roland-Morris disability questionnaire; SF-MPQ, short-form McGill pain questionnaire; SMT, spinal manual therapy; VAS, visual analogue scale; TrA, transversus abdominis; MF, multifi dus. Min denotes minimum; max, maximum. E352 www.spinejournal.com March 2013 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
• 4.
  LITERATURE REVIEW MotorControl Exercise Reduces Pain and Disability in LBP • Byström et al TABLE 2. Trials Comparing Motor Control Exercise With Spinal Manual Therapy Study PEDro Scale Participants Intervention Outcome/Follow-up Ferreira et al 35 8/10, high quality N = 240. Male and female, 18–80 (mean, 53.6) yr. LBP ≥ 3 mo. (1) MCE. (2) SMT. Up to 12 sessions during 8 wk. Pain (VAS); disability (RMDQ), 8 wk; 6 and 12 mo Goldby et al 37 4/10, low quality N = 346. Male and female, 18–65 (mean, 42.0) yr. LBP ≥ 12 wk. (1) MCE. 10 sessions. (2) SMT. Max 10 sessions. Pain (NRS); disability (mODI), 3, 6, 12, and 24 mo 5/10, low quality N = 47. Male and female, 18–60 (mean, 38) yr. Subacute and chronic LBP, 89.4% of participants had a duration ≥ 12 wk. (1) MCE. 6 sessions during 6 wk, daily home training. (2) SMT. 6 sessions during 6 wk. Pain (VAS); disability (ODI), 3 and 12 mo LBP indicates low back pain; max, maximum; MCE, motor control exercise; Min, minimum; mODI, modifi ed Oswestry disability index; NRS, numerical rating scale; ODI, Oswestry low back pain disability questionnaire; RMDQ, Roland-Morris disability questionnaire; SMT, spinal manual therapy; VAS, visual analogue scale. Motor Control Exercise Versus Multimodal Physical Therapy Four studies compared MCE with multimodal physical therapy ( Table 4 ), but it was only possible to carry out a pooled analysis in the intermediate term because the lack of reported short- and long-term outcomes. 34 , 41 – 43 The results favored MCE with regard to pain (WMD, − 14.20; CI, − 21.23 to − 7.16) and disability (WMD, − 12.98; CI, − 19.49 to − 6.47) ( Figure 4 ). A single study 43 favored MCE in the short term with regard to pain and disability, whereas no signifi cant long term difference was reported in another single study. 34 Motor Control Exercise as Part of a Multimodal Intervention Versus the Other Components of that Intervention A pooled analysis could not be carried out in this category, because the 2 included studies reported outcomes at differ-ent time points ( Table 5 ). 44 , 45 A single study 44 favored general trunk strengthening compared with a combination of MCE and general trunk strengthening with regard to disability in the short term ( Figure 5 ). No other signifi cant differences were reported. Rasmussen-Barr et al 38 intermediate (WMD, − 4.86; CI, − 8.59 to − 1.13), and long term (WMD, − 4.72; CI, − 8.81 to − 0.63) ( Figure 1 ). Motor Control Exercise Versus Spinal Manual Therapy In this category, the pooled analysis included 3 studies ( Table 2 ). 35 , 37 , 38 Compared with spinal manual therapy, MCE was superior with regard to disability in the short (WMD, − 6.12; CI, − 11.94 to − 0.30), intermediate (WMD, − 5.27; CI, − 9.52 to − 1.01), and long term (WMD, − 5.76; CI, − 9.21 to − 2.32). No signifi cant differences were, however, found with regard to pain ( Figure 2 ). Motor Control Exercise Versus Minimal Intervention Two studies compared MCE with minimal intervention con-cerning pain. 37 , 39 The pooled results favored MCE with regard to the short (WMD, − 12.48; CI, − 19.04 to − 5.93), inter-mediate (WMD, − 10.18; CI, − 16.64 to − 3.72), and long term (WMD, − 13.32; CI, − 19.75 to − 6.90). Three studies compared MCE with minimal intervention concerning dis-ability ( Table 3 ). 37 , 39 , 40 The pooled results favored MCE in the short (WMD, − 9.00; CI, − 15.28 to − 2.73), intermedi-ate (WMD, − 5.62; CI, − 10.46 to − 0.77), and long term (WMD, − 6.64; CI, − 11.72 to − 1.57) ( Figure 3 ). TABLE 3. Trials Comparing Motor Control Exercise With Minimal Intervention Study PEDro Scale Participants Intervention Outcome/Follow-up Costa et al 39 9/10, high quality N = 154. Male and female, 18–80 (mean, 53.7) yr. LBP ≥ 3 mo. (1) MCE. (2) Placebo short-wave therapy and ultrasound. 12 sessions during 8 wk. Pain (NRS); disability (RMDQ), 2, 6, and 12 mo Goldby et al 37 4/10, low quality N = 346. Male and female, 18–65 (mean, 42.0) yr. LBP ≥ 12 wk. (1) MCE. 10 sessions. (2) Education. 1 session. Pain (NRS); disability (mODI), 3, 6, 12, and 24 mo Shaughnessy and Caulfi eld 40 5/10, low quality N = 41. Male and female, 20–60 yr. LBP ≥ 12 wk. (1) MCE. 10 sessions during 10 wk. (2) Control. No intervention. Disability (ODI, RMDQ), 10 wk LBP indicates low back pain; MCE, motor control exercise; mODI, modifi ed Oswestry disability index; NRS, numerical rating scale; ODI, Oswestry low back pain disability questionnaire; RMDQ, Roland-Morris disability questionnaire. Spine www.spinejournal.com E353 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
• 5.
  LITERATURE REVIEW MotorControl Exercise Reduces Pain and Disability in LBP • Byström et al TABLE 4. Trials Comparing Motor Control Exercise With Multimodal Physical Therapy Study PEDro Scale Participants Intervention Outcome/Follow-up Kumar et al 41 5/10, low quality N = 141. Male and female, (1) MCE. (2) Ultrasound, electrotherapy, lumbar strengthening. 20 sessions, then follow-up for 180 d. Pain (VAS), 180 d (1) MCE. (2) Ultrasound, electrotherapy, lumbar strengthening. 20 sessions, then follow-up for 180 d. Pain (VAS), 180 d Critchley et al 34 7/10, high quality N = 212. Male and female, ≥ 18 (1) MCE, individual PT followed by group exercises. Max 8 sessions, 90 min/session. (2) Usual outpatient PT, passive PT & GE. Max 12 sessions, 30 min/session. Disability (RMDQ); pain (0–100), 6, 12, and 18 mo 16–49 (mean, 31) yr. Recurrent LBP, current episode > 3 mo. Spondylolysis/ spondylolisthesis. (1) MCE. 10-week treatment, directed by PT on a weekly basis. Daily home exercise. (2) Control. 10-week treatment directed by the patient’s medical practitioner. Passive PT and GE. Pain (SF-MPQ); disability (ODI), 3, 6, and 30 mo GE indicates general exercise; LBP, low back pain; MCE, motor control exercise; ODI, Oswestry low back pain disability questionnaire; PT, physiotherapist or physiotherapy; RMDQ, Roland-Morris disability questionnaire; SF-MPQ, short-form McGill pain questionnaire; VAS, visual analogue scale. present analysis and that by Macedo et al 18 may be due to our inclusion of 4 recent studies. 30 – 33 The difference in results could however also be due to the application of stricter inclu-sion criteria in the current study, as recommended by the Cochrane Back Review Group. 24 Two studies 47 , 48 included by Macedo et al 18 were excluded from the present meta-analysis because they did not provide a clear contrast for MCE. The results presented in this meta-analysis suggest that MCE is superior to spinal manual therapy with regard to dis-ability during all time periods, but not with regard to pain. In contrast, Macedo et al 18 found only a signifi cant difference in the intermediate term with regard to both disability and pain. These differences may be due to the fact that Macedo et al 18 included a study, 34 which in the present study was included in the category “MCE versus multimodal physical therapy.” The present study reveals that MCE is more effective than minimal intervention in reducing both pain and disability 20–40 (mean, 35.08) yr. Subacute and chronic LPB, mean duration 33.65 mo. Kumar et al 42 7/10, high quality N = 102. Male, 20–40 (mean, 34.06) yr. Subacute and chronic LPB, mean duration 25.37 mo. (mean, 44) yr. LPB ≥ 12 wk. O’Sullivan et al 43 7/10, high quality N = 44. Male and female, DISCUSSION The objective of the present meta-analysis was to establish the effect of MCE with regard to pain and disability in patients with chronic and recurrent LBP. The pooled results favored MCE compared with general exercise with regard to pain in the short and intermediate term and with regard to disabil-ity during all time periods. MCE was also superior to spinal manual therapy with regard to disability during all time periods but not with regard to pain. Compared with minimal intervention, MCE was superior with regard to both pain and disability during all time periods. In contrast to these results, a previous, pooled analysis by Macedo et al 18 reports no signifi cant difference between MCE and general exercise, with the exception of disability in the short term. The results of the present study contrast with the opinion that any effects of MCE are merely due to the gen-eral effects of physical exercise. 46 The differences between the TABLE 5. Trials Comparing Motor Control Exercise as Part of Multimodal Treatment With the Other Components of That Treatment Study PEDroScale Participants Intervention Outcome/Follow-up Koumantakis et al 44 7/10, high quality N = 55. Male and female. Mean age, 37.3 yr. Recurrent LBP, current episode ≥ 6 wk. (1) MCE + GE. (2) GE: trunk strengthening. Twice per week for 8 wk. Pain (SF-MPQ, VAS); disability (RMDQ), 3 mo Cairns et al 45 7/10, high quality N = 97. Male and female, 18–60 (mean, 38.7) yr. Recurrent LBP, average duration of current episode 8.7 mo. (1) MCE. (2) Conventional PT. Both groups received passive PT and GE. Maximum of 12 sessions during 12 wk. Disability (RMDQ); pain (SF-MPQ, NRS), 12 mo GE indicates general exercise; LBP, low back pain; MCE, motor control exercise; NRS, numerical rating scale; ODI, Oswestry low back pain disability questionnaire; PT, physiotherapist or physiotherapy; RMDQ, Roland-Morris disability questionnaire; SF-MPQ, short-form McGill pain questionnaire; VAS, visual analogue scale. E354 www.spinejournal.com March 2013 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
• 6.
  LITERATURE REVIEW MotorControl Exercise Reduces Pain and Disability in LBP • Byström et al Figure 2. Motor control exercise versus spinal manual therapy. The for-est plot shows mean difference (gray squares) and 95% confi dence interval (95% CI) of individual trials, and pooled, weighted mean dif-ference and 95% CI (black diamond) of all trials. All outcomes have been transformed to a common 0 to 100 scale. studies was 6.4, that is, they were generally of high quality. It therefore seems unlikely that the validity of the results would be affected by poor study quality. The included studies exhib-ited heterogeneity in the population, as well as in LBP diag-nosis and the MCE protocols with regard to parameters such as the length of intervention, methods used for feedback, etc . This makes it harder to state how the results relate to the indi-vidual patient and any specifi c MCE protocol. One methodological shortcoming of the current study was that several studies did not report the change from baseline SD, forcing us to impute this measure. In future studies, out-comes should preferably be reported as the mean change from baseline and the change from baseline SD. The conservative approach taken in this study, in the choice of the correlation coeffi cient, may have resulted in an underestimation of the statistical signifi cance of the treatment effect. Despite this Figure 1. Motor control exercise (MCE) versus general exercise. The forest plot shows mean difference (gray squares) and 95% confi dence interval (95% CI) of individual trials, and pooled, weighted mean difference and 95% CI (black diamond) of all trials. All outcomes have been transformed to a common 0–100 scale. (a) MCE versus sling exercise. (b) MCE versus trunk strengthening and stretching. during the short, medium, and long term. This result con-curs with the strong evidence for the effectiveness of exercise therapy in the treatment of chronic LBP. 49 Due to a shortage of RCTs, no conclusion could be drawn on the effectiveness of MCE compared with multimodal physical therapy. There was also a lack of RCTs studying MCE as part of a multi-modal treatment. The quality of the included studies ranged from 4 to 9 on the PEDro scale. The average score of the 16 included Spine www.spinejournal.com E355 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
• 7.
  LITERATURE REVIEW MotorControl Exercise Reduces Pain and Disability in LBP • Byström et al Figure 4. Motor control exercise versus multimodal physical therapy. The forest plot shows mean difference (gray squares) and 95% con-fi dence interval (95% CI) of individual trials, and pooled, weighted mean difference and 95% CI (black diamond) of all trials. All outcomes have been transformed to a common 0 to 100 scale. should focus on associations between physical changes of the deep abdominals and improvement in pain and disability. So far, only one study has reported a moderate correlation. 54 Figure 3. Motor control exercise versus minimal intervention. The for-est plot shows mean difference between interventions (gray squares) and 95% confi dence interval (95% CI) of individual trials, and pooled, weighted mean difference and 95% CI (black diamond) of all trials. All outcomes have been transformed to a common 0 to 100 scale. approach, signifi cant differences were found. These statisti-cal differences do, however, not automatically imply clinical signifi cance. Studies without a clear contrast for MCE were excluded. Consequently, the pooled treatment effects presented are sug-gested to represent the effect of MCE only, uncontaminated by the effects of other treatments. To provide a clear con-trast, future studies should ideally keep to a strict compari-son between an MCE group and a control group receiving a single treatment. The effect of an exercise intervention, in this case MCE, may of course always be affected by other factors, such as the patient’s beliefs and expectation, the training of the physiotherapist, and placebo effects. 50 , 51 Compared with other exercises, MCE are more body specifi c and performed with greater awareness and control. MCE may, therefore, have a greater effect on self-effi cacy, a psychosocial factor proposed to be important in the rehabilitation of musculo-skeletal disorders. 32 , 52 , 53 To establish whether MCE are solely responsible for changes in pain and disability, future studies Figure 5. Motor control exercise as part of multimodal treatment versus the other components of that treatment. The forest plot shows mean difference (gray squares) and 95% confi dence interval of individual tri-als. All outcomes have been transformed to a common 0 to 100 scale. E356 www.spinejournal.com March 2013 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
• 8.
  LITERATURE REVIEW MotorControl Exercise Reduces Pain and Disability in LBP • Byström et al One area of high priority in future research is the develop-ment of clinical methods to assess defi cits in motor control. Such methods would allow subclassifi cation of patients and the identifi cation of those in need of MCE. This was recently suggested by Ferreira et al , 54 who report that treatment effects of MCE are greater in those with poorer ability to activate TrA, implying one subgroup of patients experiencing LBP. It has been debated whether MCE should focus on isolated contraction of local musculature or if exercises should aim at engaging all abdominal and back extensor musculature to ensure spinal stability and robustness. 55 , 56 Recent research sug-gests that there is an increased activation of the deep abdomi-nals in functional and loaded postures. 11 , 57 – 62 It is to date not known if the effect of MCE on pain and physical impairment in LBP is due to the isolated activation of the local muscula-ture or subsequent stages of the intervention involving loaded postures engaging all trunk muscles. Isolated contraction of the local musculature does however seem to be necessary to restore disturbed activation patterns of the local muscula-ture in the LBP population. 63 , 64 Further research is needed to explore the underlying mechanisms to clarify the impact of these exercises on pain and functional limitations. In conclusion, the results of this pooled analysis suggest that in patients with chronic or recurring LBP, MCE is supe-rior to general exercise, manual therapy, and minimal inter-vention with regard to disability and pain. More studies are, however, needed to investigate what subgroups of patients experiencing LBP respond best to MCE. ➢ Key Points ‰ This meta-analysis includes randomized control studies of motor-control exercises until 2011. ‰ MCE is superior to general exercise in the treatment of chronic and recurrent low back pain with regard to pain and disability. ‰ MCE is superior to spinal manual therapy with regard to disability, but not with regard to pain. ‰ MCE is superior to minimal intervention with regard to pain and disability. References 1. SBU . Ont i ryggen, ont i nacken. Vol. 1 . Stockholm : The Swedish council on Technology Assessment in Health Care ; 2000 . 2. Hancock MJ , Maher CG , Latimer J , et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain . Eur Spine J 2007 ; 16 : 1539 – 50 . 3. Panjabi MM . The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement . J Spinal Disord 1992 ; 5 : 383 – 9 . 4. Panjabi MM . A hypothesis of chronic back pain: ligament sub-failure injuries lead to muscle control dysfunction . Eur Spine J 2006 ; 15 : 668 – 76 . 5. Panjabi MM . The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis . J Spinal Disord 1992 ; 5 : 390 – 6 . 6. Bergmark A . Stability of the lumbar spine. A study in mechanical engineering . Acta Orthop Scand Suppl 1989 ; 230 : 1 – 54 . 7. Hodges PW , Richardson CA . Ineffi cient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis . Spine 1996 ; 21 : 2640 – 50 . 8. MacDonald DA , Moseley GL , Hodges PW . The lumbar multifi - dus: does the evidence support clinical beliefs? Man Ther 2006 ; 11 : 254 – 63 . 9. Freeman MD , Woodham MA , Woodham AW . The role of the lumbar multifi dus in chronic low back pain: a review . PM R 2010 ; 2 : 142 – 6 . 10. Richardson C , Hodges PW , Hides J . Therapeutic Exercise for Lumbopelvic Stabilisation: A Motor Control Approach for the Treatment and Prevention of Low Back Pain . Edinburgh : Churchill Livingstone , 2004 . 11. Crommert ME , Ekblom MM , Thorstensson A . Activation of transversus abdominis varies with postural demand in standing . Gait Posture 2011 ; 33 : 473 – 7 . 12. Hodges PW , Richardson CA . Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds . Arch Phys Med Rehabil 1999 ; 80 : 1005 – 12 . 13. Hides JA , Richardson CA , Jull GA . Multifi dus muscle recovery is not automatic after resolution of acute, fi rst-episode low back pain . Spine 1996 ; 21 : 2763 – 9 . 14. Hides JA , Jull GA , Richardson CA . Long-term effects of specifi c stabilizing exercises for fi rst-episode low back pain . Spine 2001 ; 26 : E243 – 8 . 15. Danneels LA , Vanderstraeten GG , Cambier DC , et al. CT imag-ing of trunk muscles in chronic low back pain patients and healthy control subjects . Eur Spine J 2000 ; 9 : 266 – 72 . 16. Biedermann HJ , Shanks GL , Forrest WJ , et al. Power spectrum analyses of electromyographic activity. Discriminators in the differential assessment of patients with chronic low-back pain . Spine 1991 ; 16 : 1179 – 84 . 17. Mattila M , Hurme M , Alaranta H , et al. The multifi dus muscle in patients with lumbar disc herniation. A histochemical and morpho-metric analysis of intraoperative biopsies . Spine 1986 ; 11 : 732 – 8 . 18. Macedo LG , Maher CG , Latimer J , et al. Motor control exercise for persistent, nonspecifi c low back pain: a systematic review . Phys Ther 2009 ; 89 : 9 – 25 . 19. May S , Johnson R . Stabilisation exercises for low back pain: a systematic review . Physiotherapy 2008 ; 94 : 179 – 189 . 20. Hauggaard A , Persson AL . Specifi c spinal stabilisation exercises in patients with low back pain—a systematic review . Phys Ther Rev 2007 ; 12 : 233 – 248 . 21. Ferreira PH , Ferreira ML , Maher CG , et al. Specifi c stabilisation exercise for spinal and pelvic pain: a systematic review . Aust J Physiother 2006 ; 52 : 79 – 88 . 22. Rackwitz B , de Bie R , Limm H , et al. Segmental stabilizing exercises and low back pain. What is the evidence? A systematic review of randomized controlled trials . Clin Rehabil 2006 ; 20 : 553 – 67 . 23. Von Korff M . Studying the natural history of back pain . Spine 1994 ; 19 : 2041S – 46S . 24. Furlan AD , Pennick V , Bombardier C , et al. Updated method guide-lines for systematic reviews in the Cochrane Back Review Group . Spine 2009 ; 34 : 1929 – 41 . 25. PEDro . PEDro Scale . Available at: http://www.pedro.org.au/wp-content/ uploads/PEDro_scale.pdf . PEDro, 1999. Accessed Novem-ber 28, 2011. 26. Sherrington C , Herbert RD , Maher CG , et al. A database of randomized trials and systematic reviews in physiotherapy . Man Ther 2000 ; 5 : 223 – 6 . 27. RevMan . Review Manager (RevMan) [Computer program]. Version 5.1 . Copenhagen : The Nordic Cochrane Centre, The Cochrane Collaboration , 2011 . 28. Higgins J , Green S , eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011] . Available at: http://www.cochrane-handbook.org/ : The Cochrane Collaboration, 2011. Accessed October 1, 2011. 29. Deeks J , Higgins J . Statistical algorithms in Review Manager 5: Statistical Methods Group of The Cochrane Collaboration , 2010 . Available at: ims.cochrane.org/revman/documentation/Statistical-methods- in-RevMan-5.pdf. Accessed October 1, 2011. 30. Unsgaard-Tondel M , Fladmark AM , Salvesen O , et al. Motor control exercises, sling exercises, and general exercises for patients with chronic low back pain: a randomized controlled trial with 1-year follow-up . Phys Ther 2010 ; 90 : 1426 – 40 . Spine www.spinejournal.com E357 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
• 9.
  LITERATURE REVIEW MotorControl Exercise Reduces Pain and Disability in LBP • Byström et al 31. Franca FR , Burke TN , Hanada ES , et al. Segmental stabilization and muscular strengthening in chronic low back pain: a compara-tive study . Clinics 2010 ; 65 : 1013 – 7 . 32. Rasmussen-Barr E , Ang B , Arvidsson I , et al. Graded exercise for recurrent low-back pain: a randomized, controlled trial with 6-, 12-, and 36-month follow-ups . Spine 2009 ; 34 : 221 – 8 . 33. Akbari A , Khorashadizadeh S , Abdi G . The effect of motor control exercise versus general exercise on lumbar local stabilizing muscles thickness: randomized controlled trial of patients with chronic low back pain . J Back Musc Rehab 2008 ; 21 : 105 – 112 . 34. Critchley DJ , Ratcliffe J , Noonan S , et al. Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: a pragmatic randomized trial with economic evaluation . Spine 2007 ; 32 : 1474 – 81 . 35. Ferreira ML , Ferreira PH , Latimer J , et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: a randomized trial . Pain 2007 ; 131 : 31 – 7 . 36. Miller ER , Schenk RJ , Karnes JL , et al. A comparison of the McKenzie approach to a specifi c spine stabilization program for chronic low back pain . J Man ManipTher 2005 ; 13 : 103 – 112 . 37. Goldby LJ , Moore AP , Doust J , et al. A randomized controlled trial investigating the effi ciency of musculoskeletal physiotherapy on chronic low back disorder . Spine 2006 ; 31 : 1083 – 93 . 38. Rasmussen-Barr E , Nilsson-Wikmar L , Arvidsson I . Stabilizing training compared with manual treatment in sub-acute and chronic low-back pain . Man Ther 2003 ; 8 : 233 – 41 . 39. Costa LO , Maher CG , Latimer J , et al. Motor control exercise for chronic low back pain: a randomized placebo-controlled trial . Phys Ther 2009 ; 89 : 1275 – 86 . 40. Shaughnessy M , Caulfi eld B . A pilot study to investigate the effect of lumbar stabilisation exercise training on functional ability and quality of life in patients with chronic low back pain . Int J Rehabil Res 2004 ; 27 : 297 – 301 . 41. Kumar S , Sharma VP , Shukla R , et al. Comparative effi cacy of two multimodal treatments on male and female sub-groups with low back pain (part II) . J Back Musculoskelet Rehabil 2010 ; 23 : 1 – 9 . 42. Kumar S , Negi MP , Sharma VP , et al. Effi cacy of two multimodal treatments on physical strength of occupationally subgrouped male with low back pain . J Back Musculoskelet Rehabil 2009 ; 22 : 179 – 88 . 43. O’Sullivan PB , Phyty GD , Twomey LT , et al. Evaluation of specifi c stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis . Spine 1997 ; 22 : 2959 – 67 . 44. Koumantakis GA , Watson PJ , Oldham JA . Trunk muscle stabili-zation training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain . Phys Ther 2005 ; 85 : 209 – 25 . 45. Cairns MC , Foster NE , Wright C . Randomized controlled trial of specifi c spinal stabilization exercises and conventional physiother-apy for recurrent low back pain . Spine 2006 : E670 – 81 . 46. Lederman E . The myth of core stability . J Bodyw Mov Ther 2010 ; 14 : 84 – 98 . 47. Kladny B , Fischer FC , Haase I . [Evaluation of specifi c stabiliz-ing exercise in the treatment of low back pain and lumbar disk disease in outpatient rehabilitation] . Z Orthop Ihre Grenzgeb 2003 ; 141 : 401 – 5 . 48. Stevens V , Crombez G , Parlevliet T , et al. The effectiveness of specifi c exercise therapy versus device exercise therapy in the treat-ment of chronic low back pain patients . Proceedings of the 6th Interdisciplinary World Congress of Low Back and Pelvic Pain ; 2007 ; Barcelona, Spain . 49. SBU . Ont i ryggen, ont i nacken. Vol. 2. Stockholm : The Swedish council on Technology Assessment in Health Care ; 2000 . 50. Henchoz Y , Kai-Lik So A . Exercise and nonspecifi c low back pain: a literature review . Joint Bone Spine 2008 ; 75 : 533 – 9 . 51. Maul I , Laubli T , Oliveri M , et al. Long-term effects of supervised physical training in secondary prevention of low back pain . Eur Spine J 2005 ; 14 : 599 – 611 . 52. Rasmussen-Barr E , Campello M , Arvidsson I , et al. Factors pre-dicting clinical outcome 12 and 36 months after an exercise inter-vention for recurrent low-back pain . Disabil Rehabil 2012 ; 34 : 136 – 44 . 53. Thomee P , Wahrborg P , Borjesson M , et al. Self-effi cacy of knee function as a pre-operative predictor of outcome 1 year after ante-rior cruciate ligament reconstruction . Knee Surg Sports Traumatol Arthrosc 2008 ; 16 : 118 – 27 . 54. Ferreira PH , Ferreira ML , Maher CG , et al. Changes in recruitment of transversus abdominis correlate with disability in people with chronic low back pain . Br J Sports Med 2010 ; 44 : 1166 – 72 . 55. McGill S . Low Back Disorders: Evidence-based Prevention and Rehabilitation . Champaign, Illinois : Human Kinetics ; 2007 . 56. Reeves P. , Narendra KS , Cholewicki J. Spine stability: the six blind men and the elephant Clin Biomech 2007 ; 3 : 266 – 74 . 57. Eriksson Crommert AE , Thorstensson A . Trunk muscle reactions to sudden unexpected and expected perturbations in the absence of upright postural demand . Exp Brain Res 2009 ; 196 : 385 – 92 . 58. Mew R . Comparison of changes in abdominal muscle thick-ness between standing and crook lying during active abdominal hollowing using ultrasound imaging . Man Ther 2009 ; 14 : 690 – 5 . 59. McGill SM , Karpowicz A , Fenwick CM , et al. Exercises for the torso performed in a standing posture: spine and hip motion and motor patterns and spine load . J Strength Cond Res 2009 ; 23 : 455 – 64 . 60. Ainscough-Potts AM , Morrissey MC , Critchley D . The response of the transverse abdominis and internal oblique muscles to different postures . Man Ther 2006 ; 11 : 54 – 60 . 61. Rasouli O , Arab AM , Jaberzadeh S . Ultrasound measurement of deep abdominal muscle activity in sitting positions with different stability levels in subjects with and without chronic low back pain . Man Ther 2011 ; 16 : 388 – 393 . 62. Pinto RF , Ferreira PH , Franco MR , et al. The effect of lumbar pos-ture on abdominal muscle thickness during an isometric leg task in people with and without non-specifi c low back pain . Man Ther 2011 ; 16 : 578 – 584 . 63. Tsao H , Hodges PW . Immediate changes in feed forward postural adjustments following voluntary motor training . Exp Brain Res 2007 ; 181 : 537 – 46 . 64. Hodges PW . Pain and motor control: from the laboratory to rehabilitation . J Elec Kinesiol 2011 ; 21 : 220 – 8 . E358 www.spinejournal.com March 2013 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.