The Study: Predicting Response to Motor Control Exercises and Graded Activity for Low Back Pain Patients: Preplanned Secondary Analysis of a Randomized Controlled Trial

The Facts:

a. This article is from Physical Therapy which is the Journal of the American Physical Therapy Association.

b. The authors cite evidence that “Current treatments for low back pain have small effects.”

c. The authors indicate that while exercise is used in low back pain cases and is endorsed by various guidelines its effect is small.

d. The authors hoped to find characteristics in patients who suffered from low back pain that would improve if they were treated with graded activity or motor control exercises.

e. 172 subjects.

f. The subjects underwent 12 exercise sessions in the first 8 week period and then that was followed by “booster” sessions again at 4 and 10 months.

g. The authors found that those patients who had a high reported score on a clinical instability questionnaire when they entered the program responded better to motor control (lumbar stabilization) exercise.

h. Those that had a low score on that questionnaire did better with graded activity (i.e. exercise that seeks “to increase activity tolerance by addressing pain-related fear, kinesiophobia and unhelpful beliefs/behavior about back pain while at the same time correcting physical impairments such as endurance, muscle strength and balance.”)

i. The other factors they looked at (psychological features, physical activity level, and walking tolerance) did not allow them to predict which of these two treatments (motor control exercises or graded activity) would be of the most benefit.
Take Home:
Patients with reported instability problems may respond better to motor control exercises while those who do not have that problem may respond better to graded activity.

Reviewer’s Comments:
It’s been a long day. I’m tiring of all the talk in the scientific community about how low back pain treatment really does very little. I’m a science geek and I read a lot of literature. (My thanks to the groups whose monetary support allows me to do that. ) There seems to be a current trend to say that the natural progression of the condition (basically time alone) will account for most of the results in the majority of LBP cases. But there are also a lot of studies that say chiropractic care is pretty good stuff.

And just to make it plain when it comes to chiropractic, I think we should all remember that just like it says in the first chiropractic book, Modernized Chiropractic. There is no chiropractic without the thrust [adjustment]. Then other things like exercise and restoring the curves with traction and many other types of care can be added. But, as chiropractors we need to remember that it starts with an adjustment.

Reviewer: Roger Coleman DC

Editor’s Comments: This was pretty interesting. By breaking patients into the two subgroups, as opposed to a “one size fits most” approach to exercise, we may be able to significantly increase the total number of responders. The authors project that while currently the estimated benefit effect of exercise on LBP is relatively small (3.4 on a 0-100 point scale as shown in a recent meta-analysis of 43 clinical trials), simply prequalifying patients to receive either stabilization or graded activity programs could potentially raise the benefit to 18.1 points. That’s a very large increase in benefit simply from taking the time to prequalify your patients to make sure they are getting the most effective intervention.

Editor: Mark R. Payne DC

Reference: Macedo LG, Maher CG, Hancock M, Kamper SJ, McAuley J, Stanton TR, Stafford R, Hodges PW. Predicting Response to Motor Control Exercises and Graded Activity for Low Back Pain Patients: Preplanned Secondary Analysis of a Randomized Controlled Trial. Phsy Ther 2014 Jul 10. [Epub ahead of print]

Link to Abstract:http://www.ncbi.nlm.nih.gov/pubmed/25013000

Phys Ther. 2014 Jul 10. [Epub ahead of print]
Predicting Response to Motor Control Exercises and Graded Activity for Low Back Pain Patients: Preplanned Secondary Analysis of a Randomized Controlled Trial.
Macedo LG.

Abstract
BACKGROUND:
Current treatments for low back pain have small effects. A research priority is to identify patient characteristics associated with larger effects for specific interventions.

OBJECTIVE:
The aim of this study was to identify simple clinical characteristics of patients with chronic low back pain who would benefit more from either motor control exercises or graded activity.
DESIGN:
This study was a secondary analysis of the results of a randomized controlled trial.

METHODS:
One hundred seventy-two patients with chronic low back pain were enrolled in the trial, which was conducted in Australian physical therapy clinics. The treatment consisted of 12 initial exercise sessions over an 8-week period and booster sessions at 4 and 10 months following randomization. The putative effect modifiers (psychosocial features, physical activity level, walking tolerance, and self-reported signs of clinical instability) were measured at baseline. Measures of pain and function (both measured on a 0-10 scale) were taken at baseline and at 2, 6, and 12 months by a blinded assessor.

RESULTS:
Self-reported clinical instability was a statistically significant and clinically important modifier of treatment response for 12-month function (interaction: 2.72; 95% confidence interval=1.39 to 4.06). Participants with high scores on the clinical instability questionnaire (≥9) did 0.76 points better with motor control exercises, whereas those who had low scores (<9) did 1.93 points better with graded activity. Most other effect modifiers investigated did not appear to be useful in identifying preferential response to exercise type.
LIMITATIONS:
The psychometric properties of the instability questionnaire have not been fully tested.

CONCLUSIONS:
A simple 15-item questionnaire of features considered indicative of clinical instability can identify patients who respond best to either motor control exercises or graded activity.