Manual Therapy 2015 (Oct); 20 (5): 672–679 ~ FULL TEXT
Jeannette Saner, Jan Kool, Judith M. Sieben, Hannu Luomajoki, Carolien HG. Bastiaenen, Rob A. de Bie
Zurich University of Applied Sciences ZHAW,
School of Health Professions,
Institute of Physiotherapy,
Postfach 8401, Winterthur, Switzerland
BACKGROUND: Exercise is an effective treatment for patients with sub-acute and chronic non-specific low back pain (NSLBP). Previous studies have shown that a subgroup of patients with NSLBP and movement control impairment (MCI) can be diagnosed with substantial reliability. However, which type of exercises are most beneficial to this subgroup is still unknown.
OBJECTIVES: The effectiveness of a specific exercise treatment to improve movement control was tested in this study.
METHODS: Using a multicentre randomised controlled trial (RCT), we compared exercises that targeted movement control impairment (MCI) (MC) with a general exercise (GE) treatment. After randomisation, patients in both groups n(MC = 52; GE = 54) were treated in eight private physiotherapy practices and five hospital outpatient physiotherapy centres. Follow-up measurements were taken at post-treatment, six months and 12 months. The primary outcome measurement was the Patient Specific Function Scale (PSFS).
RESULTS: Patient Specific Function Scale (PSFS) showed no difference between groups after treatment, or at six months and 12 months. Secondary outcome analysis for pain and disability, measured with the Graded Chronic Pain scale and the Roland Morris Disability Questionnaire respectively, showed that a small improvement post-treatment levelled off over the long term. Both groups improved significantly (p < 0.001) over the course of one year.
CONCLUSION: This study found no additional benefit of specific exercises targeting movement control impairment (MCI).
KEYWORDS: Clinical trial; Disability; Exercise; Low back pain; Movement control impairment; Randomised controlled trial
From the FULL TEXT Article:
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 (Kolb et al. , 2011, Stanton et al. , 2008). In most
cases, according to guidelines, a specific diagnosis is not possible and the
complaints are labelled as non-specific low back pain (NSLBP) (Airaksinen, Brox,
2006, Waddell, 1987).
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 and O'Sullivan, 2011, Dankaerts et al. ,
2006). 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, (Carlsson and Rasmussen-Barr,
2013, O'Sullivan, 2005, Sahrmann, 2002). 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, 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, Kool, 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 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.
Methods and Material
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: 2010-0034/5. The protocol has been previously published (Saner et al.
Patients presenting with sub-acute or chronic low back pain (persisting for longer
than six weeks and no radiating symptoms below the knee) were recruited. Age had
to be 18 to 75 years. Eligible patients also had to present with: predefined MCI
complaints (pain provocation in static positions) (Dankaerts and O'Sullivan, 2011),
together with a score of two or more positive results out of the six MCI tests
(Luomajoki, Kool, 2007). Disability levels had to be at least five points on the Roland
Morris Disability Questionnaire (RMDQ) (Pengel et al. , 2004, Roland and Morris,
1983, Wiesinger et al. , 1999).
Excluded were patients
(1) with LBP due to known or suspected specific causes¸ with recent surgery on the spine (< 6 weeks);
(2) with spondylodesis;
(3) with comorbid health conditions, which limited exercise training.
(4) To focus on patients with pain responding to movement, we also excluded patients complaining of
constant pain and/or pain below the knee.
(5) To avoid confounding by psychosocial factors, patients with a score of more than 130 on the Örebrö Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) (Linton and Boersma, 2003) and/or
(6) more than 3 months of sick leave due to LBP were also excluded. German language had to be sufficient to understand study information, instructions and questionnaires. For further details see flow chart Figure 1.
Randomisation and blinding
Following signing informed consent, patients attended baseline assessment, which
was conducted by an independent, experienced and specially-trained
physiotherapist. Eligible patients were randomly allocated to one of two groups. The
computer-generated randomisation schedule was produced before trial start, using
block-randomisation with a block size of four. Group allocation was communicated to
the therapist by means of telephone contact from an independent research assistant
at the ZHAW. Outcome assessors and data analysts were blinded to the allocation
and were not involved in treatment throughout the trial. Blinding of patients and
physiotherapists to the allocation was not possible, but patients were kept naïve to
the specific research goal. Physiotherapists of the MC group received all baseline
information concerning the MCI sub-classification and instruction on the six physical
tests, in order to plan and apply a specific treatment. All other physiotherapists
involved remained masked for initial assessments and trial results.
Patients in both groups received individual treatment sessions of 30 minutes,
preferably twice per week, over a period of nine to 12 weeks. Progression of the
treatment, in accordance with the treatment protocol, was determined by the
physiotherapist. Ten minutes of each session was allowed for other physiotherapy
applications, where necessary. The length and type of additional interventions were
recorded and monitored. All patients received instructions for a minimum of three
home exercises and were encouraged to practise them at least twice a week for up
to one year after treatment. Patients were contacted by telephone after six months
and encouraged to maintain the training.
Movement control (MC) treatment consisted of active exercises addressing the pain-provoking postures and control of the impaired movement(s). These were
assessed and classified at baseline, as proposed by O’Sullivan and Luomajoki
(Dankaerts, O'Sullivan, 2006, O'Sullivan, 2005) (Luomajoki, Kool, 2010). As initial
exercises, patients learned to perform controlled movements with low load in
supported positions. Later they progressed to open chain positions, to exercises
involving controlled movements with increased load and to specific functional tasks.
Strength and endurance training was allowed once movement control was achieved.
Following the rationale that the MC test battery is representative of functional MCI,
the focus of the treatment was on functional restoration of the impaired
movement(s). Exercises aimed specifically at local lumbar stabilising muscles (Hides
et al. , 2001), or treatment according to behavioural classification as recently
proposed by O’Sullivan (O'Sullivan, 2012), were not included in the MCI treatment
protocol. For example, patient A, when asked to bend forward without moving the
lower part of the spine, was not able to stabilise the lumbar spine: this MCI was
classified as flexion impairment, and the corresponding test is called “waiter’s bow”.
In treatment, the patient learns to control the lumbar spine stepwise: initially
performing exercises with hip movements only in well-supported body positions
(such as lying and sitting) and gradually progressing to exercises in standing. Load,
frequency and velocity can gradually be increased once the movement is retrained.
The ultimate goal is that patient A should be able to move freely and automatically in
complex functional situations according to his personal needs in daily life.
General exercise (GE) treatment aimed to improve the muscular strength of the
lumbar and pelvic region and legs. In a standardised programme, as described in a
study manual, all relevant muscle groups (abdominals, erector spinae, gluteals,
quadriceps and hamstrings) were addressed in each treatment (Koumantakis,
Watson, 2005). Start load and progression were assessed individually and followed
a submaximal training protocol, according to the guidelines of the American College
of Sports Medicine (Whaley, 2006).
The main contrast between the two programmes was the tailored-exercise training
targeting functional improvement of MCI in the experimental group, as opposed to
the non-specific general strength training performed by the control group.
All therapists showed a positive attitude towards their treatment group and had used
the treatments in their daily practice. Therapists in the MC group were either trained
to OMT (Orthopaedic Manual Therapy) standard or were novice physiotherapists
working under the supervision of a highly-qualified OMT clinician of the ZHAW. All
physiotherapists attended at least four hours of specific training on the protocol of
their respective treatment. Additionally, they received a manual of conduct and
exercise procedures. The therapists reported the trained exercises, number and
description of home exercises and other interventions for each patient in a written
Demographic and psychosocial characteristics of age, sex, height, weight, sports
activities, work load, work status, sickness abscence, medication, duration of LBP-related symptoms and Örebrö musculoskeletal pain questionnaire (ÖMPQ) were
recorded at baseline.
Measurements of outcome were taken at baseline, post-treatment, after six months
and 12 months. Outcome measures pre- and post-treatment were obtained by a
research assistant onsite. Research assistants at the study centre collected primary
outcome measures at six months and 12 months by telephone. On this occasion,
they communicated the questionnaire on secondary outcomes, which were delivered
and returned by postal mail.
Primary outcome was patient-specific LBP-related activity limitation measured with
the Patient Specific Functional Scale (PSFS), the latter having shown excellent
reliability for mechanical and chronic LBP (Hall et al. , 2011, Horn et al. , 2012,
Stratford P, 1995) and concurrent validity with Roland-Morris Disability Questionnaire
(RMDQ). PSFS was selected because it showed good responsiveness in patients
with moderate LBP complaints and reflected patients’ individual relevant limitations
(Hall et al. , 2010, Pengel, Refshauge, 2004).
Secondary outcome variables were pain over the last three months (measured with
the subscales “Characteristic Pain Intensity” of the Graded Chronic Pain Scale
(GCPS) (Turk, 2011) (v. 2.0)) and disability (measured with the subscales “Disability
Score” of the GCPS and the Roland-Morris Disability Questionnaire (RMDQ) (Roland
and Morris, 1983)). Total GCPS scores for pain ranged from 0-30 and for disability
from 0-40. Reliability and validity of GCPS and RMDQ were high for the English and
the German versions (Klasen et al. , 2004, Roland and Fairbank, 2000, Wiesinger, Nuhr, 1999). More
details about outcome measurements are described in the study protocol (Saner,
Adherence and satisfaction
Adherence to treatment by patients and therapists was monitored using log books
and a comprehensive questionnaire, both during and after treatment. Patient
satisfaction was assessed with a numeric rating scale from 0 (extremely dissatisfied)
to 10 (completely satisfied) after six months and one year.
Descriptive statistics of demographic and clinical measures were performed.
Analyses followed the intention-to-treat principle. For the primary outcome, only the
first activity mentioned in the PSFS was used for analysis, i.e. the first open-ended
response item, since correlation between the averages of the three activities versus
the first activity was very high at 0.9. Univariate analysis of variance (ANOVA) for the
primary outcome and subsequent analysis of covariance (ANCOVA) analysed the
potential influence of the identified covariates of baseline differences and pain
duration. Missing data for this analysis were replaced by the group mean value
(Hollis and Campbell, 1999).
For primary and secondary outcome, we fitted a linear mixed model (LMM) to the
data with time, treatment group and the interaction time: treatment group as fixed
effects, subject was included as random intercept (Son et al. , 2012). Random
intercept models are equivalent to repeated measures ANOVA and take into account
the correlation between repeated measurements. In contrast to classical repeated
measures ANOVA, they can deal naturally with missing observations. All missing
values were handled in the model as missing at random. In a first step, the
parameters of the model were estimated; in a second step, specific contrasts were
For the intervention, we described differences of adherence between both groups
regarding frequency of home exercises and patient satisfaction. For work status
descriptive data over one year were provided.
Analyses were conducted using IBM SPSS Statistics 20. Two-sided significance was
set at p≤0.05.
Between August 2010 and February 2012 a total of 201 patients were evaluated for
eligibility. As described in the flow chart (Figure 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 participants equates to the sample size calculation (power 0.9; 2-sided ? 0.05;
10% drop out) (Saner, Kool, 2011). Follow-up data collection ended in March 2013.
Table 1 shows that most baseline characteristics were similar in both groups. There
were more men than women, participants were relatively active in sports, only 11%
were absent from work or on restricted work because of their LBP. Participants with
LBP for longer than one year comprised 80%. Patients in the MC group had
experienced a longer mean duration of pain than those in the GE group.
For unknown reasons, three patients in the MC and two in the GE group withdrew
from the study during treatment. One patient withdrew for other unrelated medical
reasons. Baseline characteristics did not differ between assessed and non-assessed
patients during follow-up, except for the duration of pain (MC/GE;9.0/15.7 years).
The attrition rate of six % was within the anticipated 10%.
Table 2 and Figure 2 show outcomes for LMM of treatment effects of PSFS at all
follow-ups. Both groups improved significantly over time (p<0.001). The time and
group interaction effect for the PSFS was not significant (p > 0.05). A slight posttreatment
trend in favour of the MC group (mean -0.4; -1.4 - 0.6, 95%CI) levelled off
at 6 months. Baseline differences and information from the literature identified pain
duration as potentially having an influence on outcomes (Dunn and Croft, 2006, Hill
et al. , 2008, Von Korff and Dunn, 2008). However, the results were not changed to a
level of significance and these variables were not taken into account for further
analysis (LMM)(Ryoo, 2011).
The minimal clinical important change was reported >0.9 on PSFS for mechanical
pain (Stratford P, 1995)and >1.9 for chronic pain (Maughan and Lewis, 2010). 95
patients (89.9%) reached the first (MC/GE;90.4%/88.9%) and 81 (76.4%) the second
Table 2 and Figure 2 show the results of GCPS and RMDQ. Pain differences were
non-significant at all follow-ups. The between-group difference for the RMDQ in
favour of the MCI group, which was significant post-treatment, was no longer
significant after six and 12 months.
As in the primary outcome, all secondary outcomes improved significantly over time
in both groups. Again, the main effect over time was shown between pre- and posttreatment
and improvements were maintained for up to one year.
All patients, who were initially on full or partial sick leave because of their back pain,
improved their work status. One patient in the GE group remained on partial sick
Patients received a mean of 8 – 9 treatment sessions (range MC 4 – 18; GE 5 – 25)
in both groups. Patients completing treatment reported a mean number of
recommended exercises of MC/GE 3.9/5.0, respectively. One year after
randomisation, approximately 46% of the patients in both groups (MC/GE;n=20/22)
reported that they still did their exercises in accordance with the recommended twice
per week or daily. Patient satisfaction with treatment was comparable between
groups. At the six months and twelve months follow-ups 70% and 80% of the
patients in both groups rated satisfaction with treatment as high to very high (8 or
more on a 0 - 10 scale) (Kool et al. , 2007).
Patients in both groups started with a mean number of impaired movement control
tests of 3.9, the MC group improved to a mean of 1.8 and the GE patients to 2.8
positive tests after treatment. The 10 minutes allocated to other physiotherapy
applications was monitored in the log book and did not exceed the allowance for any
A total of 28 physiotherapists performed the treatments. Therapists in both groups
had mixed levels of experience. Due to the two different recruitment processes,
therapists in private practice reported mean years of experience MC/GE; 12.9/9.8.
Physiotherapists from the ZHAW (four therapists in each group) were novices and
were treating 15 patients in each group.
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.
Strengths of this study
This trial was prospectively registered, the protocol was published and every attempt
was made in the design to minimise bias.
In general, patients were representative of people with mild to moderate pain and
disability as a result of their long-lasting low back disorders. Patients with a high risk
of psychosocial burden were excluded, in order to principally address the physical
aspects of NSLBP.
For the interventions, we chose two exercise programmes, which had previously
shown positive effects, with the aim of clarifying the choice of treatment for the
physiotherapist. The pragmatic approach, with 28 physiotherapists in different clinical
settings and therapists with different length of work experience, shows that the
treatments are widely applicable.
The adherence to the intervention protocol was high for therapists and patients in
both groups. A blinded research assistant, who obtained the third and fourth PSFS
results by telephone, also encouraged participants to stay compliant with their home
exercise programme. This might have supported the high adherence and follow-up
rates (Evers et al. , 2012).
Limitations of this study
The unexpected improvements in both groups may be influenced by the inclusion
criteria of the study. Previous observational studies, analysing the natural history of
LBP, have stated repeatedly that patients with previous episodes of back pain are
likely to remain in a stable situation over years with no improvement over time
(Tamcan et al. , 2010, Von Korff, 1994). In our RCT, a selection bias towards a
NSLBP population with low psychosocial influence and high self-management
competence may be present and must be considered when selecting either exercise
programme for future treatment. Additionally, the inclusion criteria of MCI - 2 positive
tests out of 6 - was designed to select patients who would have the best chance of
improvement with specific exercises. Likewise, it was not possible to blind
physiotherapists or patients due to the nature of the treatment; patients would have
noticed during treatment whether they were performing a general exercise program
or tailored, focused exercises that matched the tests they underwent at baseline.
The therapists treating patients in the MCI group had an OMT degree, which is a
two-year postgraduate specialisation in musculoskeletal physiotherapy. It was
assumed that they were sufficiently specialised in treating MCI. However, O’Sullivan
claims that it needs a further 100-hour programme to learn to treat patients in this
subgroup. Therefore, the equal results might be due to insufficient training. However,
in our opinion, treatment of MCI is achievable by every physiotherapist, should be
not too complex and form part of every physiotherapists toolbox.
Comparison with other studies
We are not aware of any results from other RCTs with the same inclusion criteria
and this type of MC treatment. In a study of moderate methodological quality, a
similar patient group, identified with the same classification system, found a
significant benefit from behaviourally-orientated exercises when compared with
spinal manipulation plus exercise (Vibe Fersum, O'Sullivan, 2013). Other than in our
study, patients were additionally classified according to their behavioural pattern.
The intervention of the experimental group followed a mixed approach of exercise
and cognitive behavioural treatment. We are aware of changes to the assessment
and treatment approaches in more recent years (O'Sullivan, 2012). Nowadays, nonspecific
low back pain disorders should be considered within the multidimensional
bio-psycho-social framework. Implementation of this approach is of major concern
regarding the „beliefs“ of the therapists in terms of how they understand and deal
The importance of exercise in NSLBP
The results of our study support previous findings that exercise in general,
regardless of the type, is beneficial for patients with NSLBP. Alongside disability,
pain, a major concern for patients, improved significantly and continuously. Clearly
both treatments share general effective aspects of exercise. All patients receive
attention to their complaints, they are introduced to exercise at their level of fitness,
and the exercises are controlled regularly. As a result, they improve their physical
activity levels, fitness and gain confidence in movement and adjustment of lifestyle.
Furthermore, the importance of general influences of the therapeutic relationship and
the effects on pain beliefs, as explained in the common factors model, may be
underestimated (Hall, Ferreira, 2010, Miciak et al. , 2012).This assumption is
supported by the high level of satisfaction with treatment in both groups. Although all
these factors are likely to explain a substantial part of the improvement in both
groups, the previously mentioned effect of some degree of selection bias towards a
sample with an existing good prognosis, cannot be ruled out.
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
patient is guided to a consistent long-term exercise lifestyle is of most importance.
Based on the results of this study, we can recommend exercise therapy for patients
with NSLBP and MCI, either using movement control or general exercise. Future
research on treatment for NSLBP may reconsider the concept of testing exercises
for specific subgroups. If the theoretical model, clinical findings, patients likely to
respond to the treatment (but with a prognosis that can be improved) and adequate
treatment goals are found, the means to treat need to have sufficient contrast. The
concept behind exercise may not be based so much on specific movements, but on
activity per se, the dosage of exercise, the kind of information and general aspects of
a physiotherapy treatment.
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 Physiotherapie, Egg; Rheumaklinik, Universitätsspital
Zurich, Zurich; Segeten Physiotherapie, Zurich; Uniklinik Balgrist, Zurich. We also
wish to thank Christa Wachter for her help in the randomisation process, André
Meichtry for statistical advice and Karen Linwood-Williams for proof reading the
The project was supported by the Swiss National Science Foundation (SNSF).
(Project no. 127240)
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