BACKGROUND: Non-specific low back pain (LBP) is a common condition. It is reported to be a major health and socioeconomic problem associated with work absenteeism, disability and high costs for patients and society. Exercise is a modestly effective treatment for chronic LBP. However, current evidence suggests that no single form of exercise is superior to another. Among the most commonly used exercise interventions is motor control exercise (MCE). MCE intervention focuses on the activation of the deep trunk muscles and targets the restoration of control and co-ordination of these muscles, progressing to more complex and functional tasks integrating the activation of deep and global trunk muscles. While there are previous systematic reviews of the effectiveness of MCE, recently published trials justify an updated systematic review.
OBJECTIVES: To evaluate the effectiveness of MCE in patients with chronic non-specific LBP.
SEARCH METHODS: We conducted electronic searches in CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers from their inception up to April 2015. We also performed citation tracking and searched the reference lists of reviews and eligible trials.
SELECTION CRITERIA: We included randomised controlled trials (RCTs) that examined the effectiveness of MCE in patients with chronic non-specific LBP. We included trials comparing MCE with no treatment, another treatment or that added MCE as a supplement to other interventions. Primary outcomes were pain intensity and disability. We considered function, quality of life, return to work or recurrence as secondary outcomes. All outcomes must have been measured with a valid and reliable instrument.
DATA COLLECTION AND ANALYSIS: Two independent review authors screened the search results, assessed risk of bias and extracted the data. A third independent review author resolved any disagreement. We assessed risk of bias using the Cochrane Back and Neck (CBN) Review Group expanded 12-item criteria (Furlan 2009). We extracted mean scores, standard deviations and sample sizes from the included trials, and if this information was not provided we calculated or estimated them using methods recommended in the Cochrane Handbook. We also contacted the authors of the trials for any missing or unclear information. We considered the following time points: short-term (less than three months after randomisation); intermediate (at least three months but less than 12 months after randomisation); and long-term (12 months or more after randomisation) follow-up. We assessed heterogeneity by visual inspection of the forest plots, and by calculating the Chi2 test and the I2 statistic. We combined results in a meta-analysis expressed as mean difference (MD) and 95% confidence interval (CI). We assessed the overall quality of the evidence using the GRADE approach.
MAIN RESULTS: We included 29 trials (n = 2431) in this review. The study sample sizes ranged from 20 to 323 participants. We considered a total of 76.6% of the included trials to have a low risk of bias, representing 86% of all participants. There is low to high quality evidence that MCE is not clinically more effective than other exercises for all follow-up periods and outcomes tested. When compared with minimal intervention, there is low to moderate quality evidence that MCE is effective for improving pain at short, intermediate and long-term follow-up with medium effect sizes (long-term, MD –12.97; 95% CI –18.51 to –7.42). There was also a clinically important difference for the outcomes function and global impression of recovery compared with minimal intervention. There is moderate to high quality evidence that there is no clinically important difference between MCE and manual therapy for all follow-up periods and outcomes tested. Finally, there is very low to low quality evidence that MCE is clinically more effective than exercise and electrophysical agents (EPA) for pain, disability, global impression of recovery and quality of life with medium to large effect sizes (pain at short term, MD –30.18; 95% CI –35.32 to –25.05). Minor or no adverse events were reported in the included trials.
AUTHORS' CONCLUSIONS: There is very low to moderate quality evidence that MCE has a clinically important effect compared with a minimal intervention for chronic low back pain. There is very low to low quality evidence that MCE has a clinically important effect compared with exercise plus EPA. There is moderate to high quality evidence that MCE provides similar outcomes to manual therapies and low to moderate quality evidence that it provides similar outcomes to other forms of exercises. Given the evidence that MCE is not superior to other forms of exercise, the choice of exercise for chronic LBP should probably depend on patient or therapist preferences, therapist training, costs and safety.
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.
BACKGROUND: Chronic musculoskeletal pain (CMP) is a major health problem, accounting for approximately one-quarter of general practice (GP) consultations in the United Kingdom (UK). Exercise and physical activity is beneficial for the most common types of CMP, such as back and knee pain. However, poor adherence to exercise and physical activity may limit long-term effectiveness. OBJECTIVES: To assess the effects of interventions to improve adherence to exercise and physical activity for people with chronic musculoskeletal pain. SEARCH STRATEGY: We searched the trials registers of relevant Cochrane Review Groups. In addition, we searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, Science Citation Index and Social Science Citation Index and reference lists of articles to October 2007. We consulted experts for unpublished trials. SELECTION CRITERIA: Randomised or quasi-randomised trials evaluating interventions that aimed to improve adherence to exercise and physical activity in adults with pain for three months and over in the axial skeleton or large peripheral joints. DATA COLLECTION AND ANALYSIS: Two of the four authors independently assessed the quality of each included trial and extracted data. We contacted study authors for missing information. MAIN RESULTS: We included 42 trials with 8243 participants, mainly with osteoarthritis and spinal pain. Methods used for improving and measuring adherence in the included trials were inconsistent. Two of the 17 trials that compared different types of exercise showed positive effects, suggesting that the type of exercise is not an important factor in improving exercise adherence. Six trials studied different methods of delivering exercise, such as supervising exercise sessions, refresher sessions and audio or videotapes of the exercises to take home. Of these, five trials found interventions improved exercise adherence. Four trials evaluated specific interventions targeting exercise adherence; three of these showed a positive effect on exercise adherence. In eight trials studying self-management programmes, six improved adherence measures. One trial found graded activity was more effective than usual care for improving exercise adherence. Cognitive behavioural therapy was effective in a trial in people with whiplash-associated disorder, but not in trials of people with other CMP. In the trials that showed a positive effect on adherence, association between clinical outcomes and exercise adherence was conflicting. AUTHORS' CONCLUSIONS: Interventions such as supervised or individualised exercise therapy and self-management techniques may enhance exercise adherence. However, high-quality, randomised trials with long-term follow up that explicitly address adherence to exercises and physical activity are needed. A standard validated measure of exercise adherence should be used consistently in future studies.
RATIONALE: This paper summarizes evidence of long-term effectiveness of physiotherapy exercise therapy for chronic low back pain (LBP). METHODS: A literature search was undertaken for experimental studies (2001-2007), which reported any post-intervention (follow-up) outcomes. Studies were critically appraised using the PEDro instrument. Comparative statistics were calculated, relative to the type of follow-up outcome data. RESULTS: Fifteen moderate quality trials were included [mean PEDro score 7.7, SD 1.3 (range 5-10)]. Nine trials reported pain scales, and six reported LBP reoccurrence. Trials which reported on pain scales at 6-month follow-up found significant differences in favour of exercise [standardized mean differences -0.57, 95%CI -0.75 to -0.39 (555 participants)]. At 12-month follow-up, a small pain scale benefit from exercise persisted [standardized mean differences -0.25, 95%CI -0.44 to 0.06 (434 participants)]. There was unconvincing evidence of exercise effectiveness on pain scales after this time. Three of the four trials which reported dichotomous outcomes at 6-month follow-up demonstrated large clinical benefits of exercise (relative risk reduction of reoccurrence 45-246%, absolute risk reduction of reoccurrence 36-42 for every 100 patients; and number needed to treat approximating 3, to prevent one patient suffering a LBP recurrence). The effect of exercise on LBP reoccurrence was variably reported beyond 6 months. CONCLUSION: Exercise programmes are effective for chronic LBP up to 6 months after treatment cessation, evidenced by pain score reduction and reoccurrence rates. The way in which follow-up data are reported assists clinical interpretation of research findings.
Non-specific low back pain (LBP) is a common condition. It is reported to be a major health and socioeconomic problem associated with work absenteeism, disability and high costs for patients and society. Exercise is a modestly effective treatment for chronic LBP. However, current evidence suggests that no single form of exercise is superior to another. Among the most commonly used exercise interventions is motor control exercise (MCE). MCE intervention focuses on the activation of the deep trunk muscles and targets the restoration of control and co-ordination of these muscles, progressing to more complex and functional tasks integrating the activation of deep and global trunk muscles. While there are previous systematic reviews of the effectiveness of MCE, recently published trials justify an updated systematic review.
OBJECTIVES:
To evaluate the effectiveness of MCE in patients with chronic non-specific LBP.
SEARCH METHODS:
We conducted electronic searches in CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers from their inception up to April 2015. We also performed citation tracking and searched the reference lists of reviews and eligible trials.
SELECTION CRITERIA:
We included randomised controlled trials (RCTs) that examined the effectiveness of MCE in patients with chronic non-specific LBP. We included trials comparing MCE with no treatment, another treatment or that added MCE as a supplement to other interventions. Primary outcomes were pain intensity and disability. We considered function, quality of life, return to work or recurrence as secondary outcomes. All outcomes must have been measured with a valid and reliable instrument.
DATA COLLECTION AND ANALYSIS:
Two independent review authors screened the search results, assessed risk of bias and extracted the data. A third independent review author resolved any disagreement. We assessed risk of bias using the Cochrane Back and Neck (CBN) Review Group expanded 12-item criteria (Furlan 2009). We extracted mean scores, standard deviations and sample sizes from the included trials, and if this information was not provided we calculated or estimated them using methods recommended in the Cochrane Handbook. We also contacted the authors of the trials for any missing or unclear information. We considered the following time points: short-term (less than three months after randomisation); intermediate (at least three months but less than 12 months after randomisation); and long-term (12 months or more after randomisation) follow-up. We assessed heterogeneity by visual inspection of the forest plots, and by calculating the Chi2 test and the I2 statistic. We combined results in a meta-analysis expressed as mean difference (MD) and 95% confidence interval (CI). We assessed the overall quality of the evidence using the GRADE approach.
MAIN RESULTS:
We included 29 trials (n = 2431) in this review. The study sample sizes ranged from 20 to 323 participants. We considered a total of 76.6% of the included trials to have a low risk of bias, representing 86% of all participants. There is low to high quality evidence that MCE is not clinically more effective than other exercises for all follow-up periods and outcomes tested. When compared with minimal intervention, there is low to moderate quality evidence that MCE is effective for improving pain at short, intermediate and long-term follow-up with medium effect sizes (long-term, MD –12.97; 95% CI –18.51 to –7.42). There was also a clinically important difference for the outcomes function and global impression of recovery compared with minimal intervention. There is moderate to high quality evidence that there is no clinically important difference between MCE and manual therapy for all follow-up periods and outcomes tested. Finally, there is very low to low quality evidence that MCE is clinically more effective than exercise and electrophysical agents (EPA) for pain, disability, global impression of recovery and quality of life with medium to large effect sizes (pain at short term, MD –30.18; 95% CI –35.32 to –25.05). Minor or no adverse events were reported in the included trials.
AUTHORS' CONCLUSIONS:
There is very low to moderate quality evidence that MCE has a clinically important effect compared with a minimal intervention for chronic low back pain. There is very low to low quality evidence that MCE has a clinically important effect compared with exercise plus EPA. There is moderate to high quality evidence that MCE provides similar outcomes to manual therapies and low to moderate quality evidence that it provides similar outcomes to other forms of exercises. Given the evidence that MCE is not superior to other forms of exercise, the choice of exercise for chronic LBP should probably depend on patient or therapist preferences, therapist training, costs and safety.
