Motor Control Exercise for Persistent, Nonspecific Low Back Pain: A Systematic Review

Motor Control Exercise for Persistent,Nonspecific Low Back Pain:A Systematic ReviewLuciana G Macedo, Christopher G Maher, Jane Latimer, James H McAuley

Background. Previous systematic reviews have concluded that the effectivenessof motor control exercise for persistent low back pain has not been clearlyestablished.

Objective. The objective of this study was to systematically review randomizedcontrolled trials evaluating the effectiveness of motor control exercises for persistentlow back pain.

Methods. Electronic databases were searched to June 2008. Pain, disability, andquality-of-life outcomes were extracted and converted to a common 0 to 100 scale.Where possible, trials were pooled using Revman 4.2.

Results. Fourteen trials were included. Seven trials compared motor control ex-ercise with minimal intervention or evaluated it as a supplement to another treat-ment. Four trials compared motor control exercise with manual therapy. Five trialscompared motor control exercise with another form of exercise. One trial comparedmotor control exercise with lumbar fusion surgery. The pooling revealed that motorcontrol exercise was better than minimal intervention in reducing pain at short-termfollow-up (weighted mean difference14.3 points, 95% confidence interval[CI]20.4 to 8.1), at intermediate follow-up (weighted mean difference13.6points, 95% CI22.4 to 4.1), and at long-term follow-up (weighted mean differ-ence14.4 points, 95% CI23.1 to 5.7) and in reducing disability at long-termfollow-up (weighted mean difference10.8 points, 95% CI18.7 to2.8). Motorcontrol exercise was better than manual therapy for pain (weighted mean differ-ence5.7 points, 95% CI10.7 to 0.8), disability (weighted mean differ-ence4.0 points, 95% CI7.6 to 0.4), and quality-of-life outcomes (weightedmean difference6.0 points, 95% CI11.2 to 0.8) at intermediate follow-upand better than other forms of exercise in reducing disability at short-term follow-up(weighted mean difference5.1 points, 95% CI8.7 to 1.4).

Conclusions. Motor control exercise is superior to minimal intervention andconfers benefit when added to another therapy for pain at all time points and fordisability at long-term follow-up. Motor control exercise is not more effective thanmanual therapy or other forms of exercise.

LG Macedo, PT, MSc, is a PhD stu-dent at The George Institute forInternational Health, The Univer-sity of Sydney, PO Box M201, Mis-senden Rd, Camperdown, Syd-ney, New South Wales, 2050Australia. Address all correspon-dence to Ms Macedo at:[email protected].

CG Maher, PT, PhD, is Director,Musculoskeletal Division, TheGeorge Institute for InternationalHealth, The University of Sydney.

J Latimer, PT, PhD, is AssociateProfessor, The George Institute forInternational Health, The Univer-sity of Sydney.

JH McAuley, PhD, is ResearchManager, The George Institute forInternational Health.

[Macedo LG, Maher CG, Latimer J,McAuley JH. Motor control exer-cise for persistent, nonspecific lowback pain: a systematic review.Phys Ther. 2009;89:925.]

2009 American Physical TherapyAssociation

Research Report

Post a Rapid Response orfind The Bottom Line:www.ptjournal.org

January 2009 Volume 89 Number 1 Physical Therapy f 9

Low back pain (LBP) is one of themain causes of disability, and,despite its high prevalence, thesource of pain is not established inthe majority of cases and the termnonspecific low back pain isused.14 One factor that has beenproposed as important in the genesisand persistence of nonspecific LBP isstability and control of the spine.4

Studies of individuals with LBP haveidentified impairments in the controlof the deep trunk muscles (eg, trans-versus abdominis and multifidus) re-sponsible for maintaining the stabil-ity of the spine.58 For example,activity of the transversus abdominismuscles9 and the multifidus muscles7

is delayed during arm movements(that challenge the stability of thespine) in individuals with LBP. Fur-thermore, there is evidence of de-creased cross-sectional area10 andincreased fatiguability11 and a sug-gestion of increased intramuscularfat in the paraspinal muscles of indi-viduals with LBP.12 Therefore, theo-retically, an intervention that aims tocorrect the changes occurring in thedeep trunk muscles and that targetsthe restoration of control and coor-dination of these muscles should beeffective in the management of per-sistent LBP.

Motor control exercise was devel-oped based on the principle that in-dividuals with LBP have a lack ofcontrol of the trunk muscles. Theidea is to use a motor learning ap-proach to retrain the optimal controland coordination of the spine. Theintervention involves the training ofpreactivation of the deep trunk mus-cles, with progression toward morecomplex static, dynamic, and func-tional tasks integrating the activationof deep and global trunk muscles.13,14

Although a number of laboratorystudies supporting the underlyingmechanism of action of motor con-trol exercises have been published inthe last decades,5,9,15 the clinical ef-

fectiveness of motor control exer-cise for persistent LBP is still un-clear.5,9,15 Three systematic reviewsof motor control exercise have beenpublished1618; however, the authorsof these reviews searched the litera-ture only up until October 2005.Hauggaard and Persson,17 the au-thors of the latest published review,included 10 trials testing the efficacyof motor control for acute, subacute,and chronic LBP. The review used asimple descriptive approach to sum-marize the results of each individualtrial. Rackwitz et al18 summarizedthe results of 7 randomized con-trolled trials of acute, subacute, andchronic LBP, and although they useda better approach to summarize theavailable evidence, no meta-analytical analysis with pooling ofthe data was used. Ferreira et al16

summarized the results of 13 ran-domized controlled trials of recur-rent, acute, subacute, and chronicLBP and cervical pain. This reviewwas the only one that included ameta-analytical approach; however,only a few trials were pooled, limit-ing the generalization of the re-sults. A meta-analytical approach issuperior to the other forms of analy-sis for systematic reviews because itprovides a treatment effect size with95% confidence interval (CI).

Consistent with the Cochrane Col-laboration,19 we felt that an updatedreview incorporating new random-ized controlled trials would make auseful contribution to the literature.In addition, a meta-analytical ap-proach, which has not been widelyused in the previous published sys-tematic reviews, can potentially adduseful information about the magni-tude of the effect of motor controlexercises. Because our main interestwas to study persistent LBP andguidelines suggest that persistentand acute LBP should be consideredseparately,1921 we included only tri-als studying patients with LBP thatpersisted beyond the acute phase.

The term persistent low back painis used to describe subacute,chronic, and recurrent pain. Thus,the objective of this study was tosystematically review randomizedcontrolled trials testing the effect ofmotor control exercise in patientswith persistent, nonspecific LBP.

MethodData Sources and SearchesA computerized electronic searchwas performed to identify relevantarticles. The search was conductedon MEDLINE (1950 to June 2008),CINAHL (1982 to June 2008), AMED(1985 to June 2008), PEDro (to June2008), and EMBASE (1988 to June2008). Key words relating to the do-mains of randomized controlled tri-als and back pain were used, as rec-ommended by the Cochrane BackReview Group.19 Terms for motorcontrol and specific stabilizationexercises were extracted from thereview by Ferreira et al.16 Subjectsubheadings and word truncations,according to each database, wereused. There was no languagerestriction.

One reviewer (LGM) screenedsearch results for potentially eligiblestudies, and 2 reviewers (LGM,CGM) independently reviewed arti-cles for eligibility. A third indepen-dent reviewer (JL) resolved any dis-agreement about inclusion of trials.Authors were contacted if more in-formation about the trial was neededto allow inclusion of the study. Re-searchers who published in the areawere contacted to help identify grayliterature and articles in press. Cita-tion tracking was performed usingISI Web of Science, and a manualsearch of the reference lists of previ-ous reviews and the eligible trialswas performed.

Study SelectionThe reviewers followed a researchprotocol, developed prior to the be-ginning of the review, that included

Motor Control Exercise for Persistent, Nonspecific LBP

10 f Physical Therapy Volume 89 Number 1 January 2009

a checklist for inclusion criteria. Ar-ticles were eligible for inclusionif they were randomized or quasi-randomized controlled trials compar-ing motor control exercise with aplacebo treatment, no treatment, oranother active treatment or whenmotor control exercise was added asa supplement to other interventions.When motor control exercise wasused in addition to other treatments,motor control exercises had to rep-resent at least 40% of the total treat-ment program. This criterion wasjudged by reading the description ofthe treatment with the reviewermaking a global yes/no judgment.

Trials were considered to have eval-uated motor control exercise if theexercise treatment was described asmotor control or specific spinal sta-bilization or core stability exerciseand where the protocol describedexercise targeting specific trunkmuscles in order to improve controland coordination of the spine andpelvis.

Randomized or quasi-randomizedcontrolled trials were included ifthey explicitly reported that a crite-rion for entry was nonspecific LBP(with or without leg pain) of at least6 weeks duration (nonacute LBP) orrecurrent LBP. Studies evaluating in-dividuals of all age groups of eithersex were included. Trials were in-cluded if one of the following out-come measures had been reported:pain, disability, quality of life, returnto work, or recurrence.

Data Extraction and QualityAssessmentThe methodological quality of the tri-als was assessed using the PEDroscale,22 with scores extracted fromthe PEDro database. Assessment ofquality of trials in the PEDro databasewas performed by 2 trained inde-pendent raters, and disagreementswere resolved by a third rater.23 Onestudy24 was extracted from a confer-

ence proceeding, and, therefore, thePEDro score was not available inthe database. However, 2 PEDro rat-ers evaluated the information avail-able in the abstract and in an initialversion of a manuscript, and a PEDroscore was given. Methodologicalquality was not an inclusioncriterion.

Three independent reviewers (LGM,CGM, JL) extracted data from eachincluded study using a standardizedextraction form. Mean scores, stan-dard deviations, and sample sizeswere extracted from the studies.When this information was not pro-vided in the trial, the values werecalculated or estimated using meth-ods recommended in the CochraneHandbook for Systematic Reviewsof Interventions.25 When there wasinsufficient information about out-comes to allow data analysis, the au-thors of the study were contacted,and all authors replied to ourinquiries.24,2628

Outcomes were extracted for painand disability for short-termfollow-up (less than 3 monthsafter randomization), intermediatefollow-up (at least 3 months but lessthan 12 months after randomiza-tion), and long-term follow-up (12months or more after randomiza-tion). When there were multipletime points that fell within the samecategory, the one that was closer tothe end of the treatment for theshort-term follow-up, closer to 6months for the intermediate follow-up, and closer to 12 months for thelong-term follow-up was used. Thesereferences for time points werebased on guidelines from the Coch-rane Back Review Group. Scores forpain and disability were converted toa 0 to 100 scale.29

Data Synthesis and AnalysisThe studies were grouped into 4treatment contrasts: (1) motor con-trol versus minimal intervention (no

intervention, general practitionercare, education) or motor control asa supplement, (2) motor control ver-sus spinal manipulative therapy, (3)motor control versus exercise, and(4) motor control versus surgery(lumbar fusion). Results were pooledwhen trials were considered suffi-ciently homogenous with respect toparticipant characteristics, interven-tions, and outcomes. I2 was calcu-lated using RevMan 4.2* to analyzestatistical heterogeneity. I2 describesthe percentage of the variability ineffect estimates that is due to heter-ogeneity rather than sampling error(chance). A value greater than 50%may be considered substantial heter-ogeneity.25 When trials were statisti-cally homogeneous (I250%),pooled effects (weighted mean dif-ference) were calculated using afixed-effect model. When trials werestatistically heterogeneous (I250%)pooled estimates of effect (weightedmean difference) were obtained us-ing a random-effects model.25 Whenthere was a single trial for the com-parison, results were expressed asmean differences and 95% CI.

ResultsStudy SelectionThe initial electronic database searchresulted in a total of 1,052 articles.Of these, 42 were selected as poten-tially eligible based on their title andabstract. Through a Web of Sciencesearch of these articles, 3 other po-tentially eligible articles were identi-fied. A total of 45 potentially eligiblearticles were considered for inclu-sion, with only 14 eligible for inclu-sion in this review (Fig. 1). Reasonsfor exclusion are shown in Figure 1for those articles2,3,15,3057 that wereexcluded from this review. Only 1 ofthe 26 experts contacted sent infor-mation to us on a new trial forinclusion.

* Copenhagen, Denmark: The Nordic Coch-rane Centre, The Cochrane Collaboration,2003.



A number of randomized controlledtrials that were included in previoussystematic reviews of motor controlexercises were not included in thisreview. Reasons for exclusion in-cluded: patients had acute but notpersistent back pain,15,51,53 patientshad neck pain and headache but notback pain,58 the trial did not use amotor control intervention accord-ing to our review definition,56 and

the trial did not have the outcomesof interest.59,60 Four new tri-als13,24,26,61 that were not included inany of the previously published re-views were included in this review,accounting for the addition of 560patients.

Methodological QualityThe methodological quality assess-ment using the PEDro scale revealed

a mean score of 6 (range28).Blinding of the therapist and blind-ing of the subject were not used inany of the trials, as would be ex-pected for an exercise therapy study.An intention-to-treat analysis wasused in 36% of the trials, and alloca-tion concealment was present in58% of the trials. One of the articles24

included in the review was from aconference proceeding, and, there-

Figure 1.Flow chart of systematic review inclusion and exclusion. RCTrandomized controlled trial.



fore, not much information on theconduct of the trial was available.With the limited information avail-able, this trial received a score of 2on the PEDro scale and was the onlytrial that was a quasi-randomizedcontrolled trial.24

Study CharacteristicsThe 14 randomized controlled trialsincluded in this review comparedmotor control exercise against an-other treatment or against no treat-ment (Tabs. 1 and 2). No placebo-controlled trials were identified.Trials were grouped into 4 treatmentcontrasts: (1) motor control exerciseversus minimal intervention or mo-tor control exercise as a supplement,(2) motor control exercise versusmanual therapy, (3) motor controlexercise versus other forms of exer-cise, and (4) motor control exerciseversus surgery.

Seven trials (603 patients) were in-cluded in the first treatment con-trast: 4 trials (343 patients) that com-pared motor control exercise withminimal intervention (no interven-tion, general practitioner care, or ed-ucation)14,27,62,63 and 3 trials (260 pa-tients) that used motor controlexercise as a supplement to othertreatment (general exercise or usualphysical therapy.28,64,65 Four trials(523 patients) compared motor con-trol exercise with manual therapy(high- or low-velocity trust).13,26,64,66

Five trials (508 patients) comparedmotor control exercise with anotherform of exercise therapy (pain man-agement, general exercises, or theMcKenzie approach).13,24,26,61,67 Onetrial (61 patients) compared motorcontrol exercise with lumbar fusionsurgery.68 The characteristics of themotor control exercise programsthat were evaluated in each trial areprovided in Table 2.

Motor Control Exercise VersusMinimal Intervention or MotorControl Exercise as a SupplementOf the 7 studies included in thistreatment contrast, 4 compared mo-tor control exercise with a minimalintervention program (usual generalpractitioner care or no interven-tion)14,27,62,63 and 3 compared motorcontrol exercise as a supplement toanother intervention versus thisother intervention alone.28,64,65

Methodological quality of the articlesranged from 4 to 8. Data for pain,disability, and quality of life wereavailable for pooling at short-term,intermediate, and long-term follow-up. Data were pooled using arandom-effects model for all compar-isons except for quality of life at in-termediate and long-term follow-ups,where a fixed-effects model wasused because I2 was smaller than50%.

The pooled results favored motorcontrol exercise for pain and disabil-ity outcomes at each follow-up, with4 of the 6 estimates of treatmenteffect being statistically significant.The random-effects model showed astatistically significant decrease inpain favoring motor control exerciseat short-term follow-up (weightedmean difference [on a 0100scale]14.3 points, 95%CI20.4 to 8.1), intermediatefollow-up (weighted mean differ-ence13.6 points, 95% CI22.4 to4.1), and long-term follow-up(weighted mean difference14.4points, 95% CI23.1 to 5.7) andin reducing disability at long-termfollow-up (weighted mean differ-ence10.8 points, 95% CI18.7to 2.8) (Fig. 2). There was no evi-dence that motor control exercisewas effective for improving qualityof life.

Motor Control Exercise VersusManual TherapyFour trials13,26,64,66 compared motorcontrol exercise with manual ther-

apy, with pain and disability out-comes measured at short-term, inter-mediate, and long-term follow-upsand quality of life measured at inter-mediate and long-term follow-ups.The methodological quality of the ar-ticles ranged from 4 to 8. Because I2

was smaller than 50% for all timepoints, a fixed-effects model wasused to pool the results. The pooledeffects for pain and disability out-comes favored motor control exer-cise, but the effects were alwayssmall and reached statistical signifi-cance for only 2 of the 6 estimates.There was a significant difference be-tween treatment groups favoringmotor control exercise for pain anddisability at intermediate follow-up(weighted mean difference5.7points, 95% CI10.7 to 0.8 forpain and weighted mean differ-ence4.0 points, 95% CI7.6 to0.4 for disability) (Fig. 3). Thepooled estimates of treatment effectson quality of life were small, favoringmotor control exercise at short-termfollow-up and favoring manual ther-apy at long-term follow-up.

Motor Control Exercise VersusOther Forms of ExerciseFive trials13,24,26,61,67 compared mo-tor control exercise with anotherform of exercise therapy. The meth-odological quality of the trials rangedfrom 2 to 8. The trial with a method-ological quality score of 2 had itsPEDro score assessed from a confer-ence proceeding and some informa-tion given by the authors.24 Resultswere pooled for pain and disabilityat short-term, intermediate, and long-term follow-ups. Because I2 wasgreater than 50% for pain at short-term follow-up and for disability atlong-term follow-up, pooled effectsfor these time points were calculatedusing a random-effects model. Allother pooled effects were calculatedusing a fixed-effects model. All esti-mates of treatment effect were small.Five of the 6 estimates favored motorcontrol exercise; however, only one



Table

1.Detailsof

theInclud

edRa

ndom

ized

Con

trolledTrialsa

Article

PatientCharacteristics,Sample

Size,an

dDurationofComplaint

Interven

tions

Outcomes

(Measure)

PED

roScore

Article

Included

inPreviousReviews

Motorcontrolexercisesversusminim

alinterven

tionormotorcontrolexercisesas

asupplemen

t

Niemisto

etal,62

2003

Patie

ntsrecruitedfrom

adve

rtisem

ent

Age

d24

46y

Mainex

clusioncrite

rion:

neurolog

ical

sign

sor

prio

rba

cksurgery

N20

4Durationof

LBP3mo

Motor

controle

xercises

muscleen

ergy

vsusua

lge

neralp

ractition

ercare

(edu

catio

n)

Pain

(VAS)

Disab

ility

(ODI)

Qua

lityof

life(hea

lth-related

qua

lity

oflife)

8Includ

edin

Ferreira

etal,16

2006

;Ra

ckwitz

etal,1820

06;

andHau

ggaa

rdet

al,1720

07

Koum

antakiset

al,65

2005

Patie

ntsfrom

anorthop

edic

clinic

inaho

spita

land

gene

ral

practition

ers

Mainex

clusioncrite

rion:

prio

rba

cksurgeryor

radiolog

ical

sign

sof

spinal

instab

ility

N55

Durationof

LBP6wk

Motor

controle

xercises

gene

rale

xercises

vsge

neral

exerciseson

ly

Pain

(VAS)

Disab

ility

(RM-24)

7Includ

edin

Ferreira

etal,16

2006

;an

dHau

ggaa

rdet

al,17

2007

OSullivan

etal,14

1997

Patie

ntswith

spon

dylolysisor

spon

dylolisthesis

Age

d16

49y

Mainex

clusioncrite

rion:

neurolog

ical

sign

sor

infla

mmatoryjointdisease

N42

Durationof

LBP3mon

ths

Motor

controle

xercises

vsusua

lgen

eral

practition

ercare

Pain

(sho

rt-form

McG

illVA

S)Disab

ility

(ODI)

7Includ

edin

Ferreira

etal,16

2006

;Ra

ckwitz

etal,1820

06;

andHau

ggaa

rdet

al,1720

07

Stug

eet

al,2820

04Pa

tientsfrom

health

care

practition

ers

Pelvic

girdle

painlateraltoL5

S1

Mainex

clusioncrite

rion:

neurolog

ical

sign

sN81

Durationof

LBP6wk

Motor

controle

xercises

usua

lphy

sicalthe

rapyvs

usua

lphy

sicalthe

rapyon

ly

Pain

(VASpainev

ening)

Disab

ility

(ODI)

7Includ

edin

Ferreira

etal,1620

06

Moseley

,2720

02Pa

tientsfrom

gene

ralp

ractition

ersan

dphy

sicalthe

rapy

clinics

Mainex

clusioncrite

rion:

worsening

neurolog

ical

sign

sN57

Durationof

LBP2mo

Motor

controle

xercises

man

ualthe

rapy

educ

ationvs

usua

lgen

eral

practition

ercare

Pain

(backpainNRS

010

)Disab

ility

(RM-18)

6Includ

edin

Ferreira

etal,16

2006

;an

dRa

ckwitz

etal,18

2006

Shau

ghne

ssyet

al,63

2004

Patie

ntsfrom

orthop

edic

clinics

Age

d20

60y

Mainex

clusioncrite

rion:

neurolog

ical

sign

sor

infla

mmatoryjointdisease

N41

Durationof

LBP3mo

Motor

controle

xercises

vsno

interven

tion

Pain

(SF-36

bodily

pain)

Disab

ility

(RM-24)

Qua

lityof

life(SF-36

gene

ral

health)

5Includ

edin

Hau

ggaa

rdet

al,17

2007

Goldb

yet

al,64

2006

19

Patie

ntsfrom

phy

sicalthe

rapyde

partm

entof

aho

spita

lAge

d18

65y

Mainex

clusioncrite

rion:

neurolog

ical

sign

sor

prio

rba

cksurgery

N12

4Durationof

LBP3wk

Motor

controle

xercises

educ

ationvs

educ

ationon

lyPa

in(backpainNRS

010

0)Disab

ility

(ODI)

Qua

lityof

life(N

othing

ham

Hea

lthProfi

le)

4Includ

edin

Ferreira

etal,16

2006

;an

dHau

ggaa

rdet

al,17

2007

(Con

tinued)



Table

1.Con

tinue

d

Article


Size,an


Interven

tions

Outcomes

(Measure)

PED

roScore

Article

Included

inPreviousReviews

Motorcontrolexercisesversusman

ual

therap

y

Ferreira

etal,1320

07Pa

tientsseekingcare

from

phy

sicalthe

rapyde

partm

ents

ofpub

licho

spita

lsAge

d18

80y

Mainex

clusioncrite

rion:

neurolog

ical

sign

sor

prio

rba

cksurgery

N16

0Durationof

LBP3mo

Motor

controle

xercises

vsspinal

man

ipulativetherap

yPa

in(VAS)

Disab

ility

(RM-24)

8Not

includ

edin

previou

sreview

s

Critch

leyet

al,26

2007

Patie

ntsrecruitedfrom

referralsby

spec

ialists

orprim

ary

care

practition

ersto

phy

sicalthe

rapyde

partm

ents

ofho

spita

lsAge

d18

yor

olde

rWith

orwith

outlegsymptomsor

neurolog

icsign

sMainex

clusioncrite

rion:

prio

rspinal

surgery,

hematolog

icdisease,

orha

dphy

sicalthe

rapyin

thelast

6mo

N14

3Durationof

LBP12

wk

Motor

controle

xercises

vsman

ualthe

rapy

home

exercisesvs

pain

man

agem

entprogram

Pain

(VAS)

Disab

ility

(RM-24)

Qua

lityof

life(EQ-5D)

7Not

includ

edin

previou

sreview

s

Rasm

ussen-Ba

rret

al,6620

03N47

Durationof

LBP6wk

Motor

controle

xercises

vsspinal

man

ipulativetherap

yPa

in(VAS)

Disab

ility

(ODI)

5Includ

edin

Ferreira

etal,16

2006

;an

dRa

ckwitz

etal,18

2006

Goldb

yet

al,6420

06Pa

tientsfrom

phy

sicalthe

rapyde

partm

entof

aho

spita

lAge

d18

65y

Mainex

clusioncrite

rion:

neurolog

ical

sign

sor

prio

rba

cksurgery

N17

3Durationof

LBP3wk

Motor

controle

xercises

educ

ationvs

spinal

man

ipulativetherap

y

educ

ation

Pain

(backpainNRS

010

0)Disab

ility

(ODI)

Qua

lityof

life(N

othing

ham

Hea

lthProfi

le)

4Includ

edin

Ferreira

etal,16

2006

;an

dHau

ggaa

rdet

al,17

2007

Motorcontrolexercisesversusother

form

sofexercise

Ferreira

etal,1320

07Pa

tientsseekingcare

from

phy

sicalthe

rapyde

partm

ents

ofpub

licho

spita

lsAge

d18

80y

Mainex

clusioncrite

rion:

neurolog

ical

sign

sor

prio

rba

cksurgery

N16

0Durationof

LBP3mo

Motor

controle

xercises

vsge

nerale

xercises

Pain

(VAS)

Disab

ility

(RM-24)

8Not

includ

edin

previou

sreview

s

Critch

leyet

al,26

2007

Patie

ntsrecruitedfrom

referralsby

spec

ialists

orprim

ary

care

practition

ersto

phy

sicalthe

rapyde

partm

ents

ofho

spita

lsAge

d18

yor

olde

rWith

orwith

outlegsymptomsor

neurolog

icsign

sMainex

clusioncrite

rion:

prio

rspinal

surgery,

hematolog

ical

disease,

orha

dphy

sicalthe

rapyin

thelast

6mo

N14

1Durationof

LBP12

wk

Motor

controle

xercises

vsman

ualthe

rapy

home

exercisesvs

pain

man

agem

entprogram

Pain

(VAS)

Disab

ility

(RM-24)

Qua

lityof

life(EQ-5D)

7Not

includ

edin

previou

sreview

s

(Con

tinued)



Table

1.Con

tinue

d

Article


Size,an


Interven

tions

Outcomes

(Measure)

PED

roScore

Article

Included

inPreviousReviews

Klad

nyet

al,6720

03Pa

tientssent

totheou

tpatient

reha

bilitationde

partm

ent

dueto

back

pain

Age

d18

55y

Patie

ntswith

orwith

outradiationor

with

orwith

outdisk

hernia

orprotrusion

Mainex

clusioncrite

ria:prio

rspinal

surgery,

arthritisof

the

joints,injurie

s,or

trau

ma

N99

Suba

cute

andch

ronic

Motor

controle

xercises

gene

rale

xercises

vsge

neral

exercises

man

ualthe

rapy

Pain

(backpainNRS

)Disab

ility

(ODI)

5Includ

edin

Ferreira

etal,16

2006

;Ra

ckwitz

etal,1820

06;

andHau

ggaa

rdet

al,1720

07

Miller

etal,6120

05Pa

tientsfrom

anou

tpatient

phy

sicalthe

rapyclinic

Age

dab

ove18

yMainex

clusioncrite

rion:

morethan

oneba

cksurgeryor

system

icinfla

mmatorydisease

N30

Durationof

LBP7wk

Motor

controle

xercises

vsMcK

enzieap

proach

Pain

(VAS)

Disab

ility

(fun

ctiona

lstatus0

100)

5Not

includ

edin

previou

sreview

s

Stev

enset

al,24

2007

Patie

ntswith

nonspec

ificLB

Pfrom

thephy

sicalm

edicine

andorthop

edic

surgeryde

partm

entof

aho

spita

lAge

d18

65y

Mainex

clusioncrite

ria:spec

ificLB

P,radicu

larsymptoms,

back

surgery,

andne

urolog

icor

system

icco

ndition

N78

Durationof

LBP3moor

recu

rren

t

Motor

controle

xercises

man

ualthe

rapy(10%

)vs

gene

rale

xercises

oftrun

kmusclefunc

tionan

dco

ordina

tion

Pain

(VAS)

Disab

ility

(QBP

DS)

Qua

lityof

life(SF-36

gene

ral

health)

2Not

includ

edin

previou

sreview

s

Motorcontrolexercisesversussurgery

Brox

etal,6820

03Pa

tientsfrom

departm

ents

oforthop

edic

surgery,

neurosurge

ry,phy

sicalm

edicine,

andreha

bilitation

Age

d25

60y

Spinede

gene

ratio

nor

spon

dylosisha

dto

bepresent

Mainex

clusioncrite

rion:

neurolog

ical

sign

sor

prio

rba

cksurgery

N61

Durationof

LBP1y

Motor

controle

xercises

cogn

itive

beha

vioral

therap

yvs

surgery

Pain

(backpain0

100scale)

Disab

ility

(ODI)

Qua

lityof

life(life

satisfactionscale)

8Includ

edin

Ferreira

etal,1620

06

aLB

Plow

back

pain,

ODI

Osw

estryDisab

ility

Inde

x,VA

Svisual

analog

scale,

RM-18

18-item

Roland

-Morris

Disab

ility

Que

stionn

aire,RM

-24

24-item

Roland

-Morris

Disab

ility

Que

stionn

aire,

NRSnu

merical

ratin

gscale,

SF-36

Med

ical

Outco

meStud

y36

-Item

Short-Fo

rmHea

lthSu

rvey

,QBP

DS

Que

becBa

ckPa

inDisab

ility

Scale,

EQ-5DEu

roQol

que

stionn

aire.



Table

2.Detailsof

theMotor

Con

trol

Exercises

Article

DurationofMotor

ControlInterven

tion

ProgressionRule

HomeProgram

Adheren

ceMean(SD)

Feed

back

Brox

etal,6820

035-wkinterven

tion(1

sessionin

thefirst

wee

k,2wkof

homeprogram

,an

dan

othe

r2wkof

trea

tmen

t)Ave

rage

duratio

nwas

abou

t25

hper

wee

k

Not

stated

2wkof

homeprogram

Adh

eren

cewas

3(7)

sessions

per

patient

Not

stated

Critch

leyet

al,26

2007

8sessions

of90

min

Prog

ressionwas

basedon

theab

ility

ofthe

patientsto

maintainastab

lean

dminim

ally

painful

spine.

Theex

ercisesaimed

toim

prove

musclemotor

controltoprovide

dyna

mic

segm

entalstabilityforthelumba

rspine.

Not

stated

Not

stated

Not

stated

Ferreira

etal,13

2007

12sessions

in8wk

Prog

ressionby

inco

rporatingmorefunc

tiona

lposition

san

dtraining

theco

ordina

tionof

all

trun

kmuscles

durin

gthosefunc

tiona

ltasks

Not

stated

Adh

eren

cewas

9.2(3.4)

sessions

per

patient

Real-tim

eultrasou

nd

Goldb

yet

al,6420

061sessionof

112hper

wee

kfor10

wk

Not

stated

Not

stated

Not

stated

Not

stated

Klad

nyet

al,6720

03Not

stated

Not

stated

Not

stated

Stated

only

that

patients

did16

.4(4.8)dof

motor

control

9.5

(3.4)dof

gene

ral

exercises

Real-tim

eultrasou

nd

Koum

antakiset

al,65

2005

2sessions

of30

to45

min

per

wee

kfor8wk

Prog

ressiontowardthego

alof

10co

ntractions

of10

sdu

ratio

n(12

wk).Prog

ressionto

func

tiona

lactivities

whe

npatientswereab

leto:(1)co

ntract

musclein

aspec

ificpattern

and(2)perform

10co

ntractions

of10

sho

lds(35

wk).Hea

vier-lo

adfunc

tiona

ltasks

wereprogressive

lyintrod

uced

inthelast

3wkof

theprogram

.

Hom

eex

ercisesinclud

edAdh

eren

cewas

12.12

(2.69)

sessions

per

patient,an

dho

me

exercisesha

dmed

ianof

23.5

sessions

Tactile

andpressure

cues

Miller

etal,6120

056wk

Trea

tmen

twas

divide

dinto

3pha

ses.

Phase1

goal

was

toperform

10repetition

sof

10-s

holdsin

diffe

rent

position

s.Ph

ase2go

alwas

contractionof

thetran

sversusab

dominisan

dmultifi

dusmuscles

with

load

ingof

thelim

bsin

diffe

rent

position

s.Ph

ase3go

alwas

more

complexload

ingex

ercises.

Patie

ntswereaskedto

perform

approximately10

15min

ofho

meex

ercises

Not

stated

Verbal,tactile,an

dpressurega

uge

Moseley

,2720

022sessions

per

wee

kfor4wk

Not

stated

Stan

dard

homeex

ercises

Not

stated

Not

stated

Niemisto

etal,62

2003

1sessionper

wee

kfor4wk

Prog

ressionwas

perform

edby

instructingthe

patientsto

perform

exercisesin

amore-

func

tiona

lman

neran

dfurthe

rintegrate

them

inda

ilyactiv

ities.

Verbal,visual,

tactile,an

dpressurega

uge

(Con

tinued)



Table

2.Con

tinue

d

Article

DurationofMotor

ControlInterven

tion

ProgressionRule

HomeProgram

Adheren

ceMean(SD)

Feed

back

OSullivan

etal,14

1997

1sessionper

wee

kfor10

wk

Holding

timeof

exerciseswas

increa

sed

grad

ually,as

wella

sthepressureon

biofee

dbackmon

itor.Goa

lwas

10co

ntractions

of10

-sho

lds.

Furthe

rlow

load

swereap

pliedby

adding

leve

rage

throug

hlim

bs.Whe

naccu

rate

activ

ationof

theco

-co

ntractionpattern

was

achiev

ed,ex

ercises

wereprogressedto

func

tiona

lholding

ofposturesan

dactiv

ities

know

nto

previou

sly

aggrav

atepatients

symptoms.

Patie

ntswereaskedto

doda

ilyex

ercisesof

approximately

101

5min

Patie

ntsco

mpletedada

ilyex

ercisesshee

tto

mon

itorad

herenc

e,bu

tresults

wereno

tpresented

Pressure

gaug

e

Rasm

ussen-Ba

rret

al,6620

031sessionof

45min

per

wee

kfor6wk

Exerciseswereprogressedby

applyinglow

load

tothemusclethroug

hthelim

bsin

diffe

rent

position

s.Pa

tientswereinstructed

inho

wto

useco

ntractionof

themuscles

durin

gactiv

ities

ofda

ilylivingan

din

situations

that

setoffpain.

Patie

ntswereaskedto

doda

ilyex

ercisesof

approximately

101

5min

Not

stated

Tactile

andpressure

gaug

e

Shau

ghne

ssyet

al,63

2004

10sessions

in10

wk

Thisco

nsistedof

two1-h

sessions

durin

gwee

k1,

two

30-m

insessions

durin

gwee

k2,

one30

-min

session

durin

gea

chof

wee

ks3

6,an

don

e30

-min

session

durin

gwee

ks8an

d10

.

Con

tractio

nswerefirst

perform

edwith

thego

alto

achiev

e10

contractions

of10

-sho

lds.

Onc

epatientswereab

leto

perform

sustaine

dco

ntractions

inlow-lo

adpostures,

theregimen

was

progressedby

adding

leve

rage

throug

hlim

bmov

emen

ts.

Patie

ntsperform

edda

ilymainten

ance

exercisesat

home

Not

stated

Verbal,visual,

tactile,an

dpressurega

uge

Stev

enset

al,24

2007

18individu

alsessions

of45

min

in12

wk(2

times

per

wee

kin

thefirst

6wkan

d1

timeper

wee

kin

thene

xt6wk)

Exerciseswerepracticed

indiffe

rent

environm

ents

andco

ntex

tsto

max

imize

tran

sfersto

daily

situations.Th

ephy

sical

therap

istwas

free

toch

oose

thetypeof

exercise

andtheprogression

hefeltmost

suita

bleforindividu

alpatient.Ba

sedon

continuo

usclinical

exam

ination,

the

trea

tmen

tproce

ssco

ntaine

daclea

rlin

eof

progression

achiev

edby

chan

ging

param

eterssuch

asposturalloa

d,redu

ction

ofattentionde

man

ds,redu

ctionof

spee

d,or

additio

nalstrateg

iesto

augm

ent

perform

ance

,with

thefin

algo

alto

obtain

func

tiona

limprove

men

t.

Daily

homeex

erciseswere

enco

urag

ed;ho

wev

er,

adhe

renc

ewas

notassessed

Not

stated

Not

stated

Stug

eet

al,2820

04Se

ssions

of30

to60

min,

3da

ysper

wee

k,for18

to20

wk

First,thefocu

swas

onthespec

ificco

ntraction

ofthetran

sversely

oriented

abdo

minal

muscle.

After

approximately4wk,

load

ing

was

progressive

lyincrea

sed.

Exercisesweremainly

perform

edat

home.

Patie

ntswereen

courag

edto

activ

atethetran

sversus

abdo

minismuscles

regu

larly

durin

gda

ilyactiv

ities.

Adh

eren

cewas

11sessions

per

patient.

80%

ofpatientsdidtheir

exercise

program

3tim

esper

wee

k,either

attheclinic

orat

home.

Not

stated



Figure 2.Forest plot of the results of randomized controlled trials comparing motor control exercises with minimal intervention or motorcontrol exercises as a supplement. Values presented are effect size (weighted mean difference) and 95% confidence interval. Thepooled effect sizes were calculated using a random-effects model except for quality of life at intermediate and long-term follow-ups.



Figure 3.Forest plot of the results of randomized controlled trials comparing motor control exercises with spinal manipulative therapy. Valuesrepresent effect size (weighted mean difference) and 95% confidence interval. The pooled effect size was calculated using afixed-effect model.



effect was statistically significant.The results showed that motor con-trol exercise was better than otherforms of exercises only for reduc-ing disability at short-term follow-up(weighted mean difference5.1points, 95% CI8.7 to 1.4) (Fig. 4).The results of a single trial26 showedno difference between treatmentgroups for quality of life at short-term follow-up.

Motor Control Exercise VersusSurgeryOnly one study68 compared motorcontrol exercise with surgery, with amethodological quality score of 8.Surgery consisted of lumbar fusionwith transpedicular screws of theL4L5 segments or the L5S1 seg-ments. Brox et al68 found no statisti-cally significant differences for pain(mean difference [on a 0100scale]9 points, 95% CI22.1 to3.5), disability (mean difference

3.3 points, 95% CI12.8 to 6.2),and quality of life (mean difference0.4 points, 95% CI1.6 to 0.8) atthe long-term follow-up (Fig. 5).

DiscussionThis systematic review provides evi-dence that motor control exercise,alone or as a supplement to anothertherapy, is effective in reducing painand disability in patients with persis-tent, nonspecific LBP. We did notfind convincing evidence that motor

Figure 4.Forest plot of the results of randomized controlled trials comparing motor control exercises with other forms of exercise. Valuesrepresent effect size (weighted mean difference) and 95% confidence interval. The pooled effect size was calculated using arandom-effects model for pain at short-term follow-up and for disability at long-term follow-up and using a fixed-effect model forall other comparisons.



control exercise was superior tomanual therapy, other forms of exer-cise, or surgery.

Figure 2 shows that there was somevariation among studies in the effectsizes for motor control exercise. Fea-tures that could influence the treat-ment effect sizes are characteristicsof the patients (eg, symptom dura-tion), characteristics of treatment im-plementation (eg, program duration,experience of the therapist), and themethodological quality of the trial.Unfortunately, there are too few tri-als to systematically evaluate the ef-fects of these features using tech-niques such as meta-regression.

An intriguing finding of this reviewwas that motor control exercise wasas effective in reducing pain and in-creasing quality of life as a less-complex form of exercise therapythat did not incorporate the retrain-ing of specific muscles that often istime consuming to therapists and pa-tients. When taking in considerationthe results for disability, motor con-trol exercise was more effective thanother forms of exercise only at short-term follow-up, but the point esti-mate was small (5.1 out of 100),showing differences between inter-ventions that may not be clinicallyimportant.

The results of a single trial68 showedthat motor control exercise was notmore effective than surgery. Thisfinding is interesting because bothinterventions target the restoration

of spinal stability, and although spi-nal stability was not directly mea-sured, the findings suggest that themotor control approach is as effec-tive in maintaining stability as an in-vasive intervention that creates sta-bility by fusing the spine. However,this was the finding of a single trial,and more research is needed to con-firm the results.

Although a motor control interven-tion has been shown to reduce pain,it is still unknown whether thesechanges are accompanied by im-provements in measures of motorcontrol. Tsao and Hodges69 haveshown improvements in motor con-trol (anticipatory contraction of thetransversus abdominis muscle duringarm movement) after a single treat-ment session where the isolation ofthe transversus abdominis musclewas trained. In a different trial, Halland colleagues70 did not find thatmotor control (anticipatory contrac-tion of the transversus abdominismuscle during arm movement and awalking task) changed after trainingthe trunk muscles in a nonisolatedmanner. Therefore, the results ofthese 2 studies support the princi-ples of a motor control interventionwhere the isolated training of thedeep trunk muscles is emphasized.However, there has not been a pub-lished randomized controlled trialthat used clinical and physiologicalmeasures to detect improvements inmotor control that can be associatedwith improvements in pain and dis-

ability and the maintenance of thesechanges.

One question that is still to be an-swered is whether individuals withreduced motor control respond bestto this intervention or whether thereare other clinical features that can beused to define a subgroup of patientswho will respond best to this type ofintervention.

A standard protocol and definitionsfor motor control exercise are yet tobe established, and this is reflectedin the wide variation among trials inhow the exercise was named andimplemented (Tab. 2). Although inmost cases OSullivan et al14 and Ri-chardson et al71 were cited as refer-ences, it is apparent from inspectionof the articles that the interventionsin the trials were quite heteroge-neous. There was variation in theduration of the exercise program,progression rule, use of home exer-cise programs, and type of feedbackused with the motor control inter-vention. As an illustration, the pro-gram lasted 10 weeks in the trial byOSullivan et al, whereas the pro-gram lasted 18 to 20 weeks in thetrial by Stuge et al.28 In the trial byFerreira et al,13 ultrasound was usedfor feedback, and Stuge et al28 usedTerapi Master exercise equipment:2 elements missing from the trial byOSullivan and colleagues.

Nordisk Terapi A/S, Kilsund 4290, Staubo,Norway.

Figure 5.Forest plot of the results of a randomized controlled trials comparing motor control exercises with surgery. Values represent meandifference and 95% confidence interval.



Detailed comparison among trials isdifficult because in many trials theauthors did not thoroughly describethe motor control intervention thatwas evaluated. Accordingly, al-though we can conclude from thisreview that motor control exercise isan effective treatment for persistentLBP, the optimal way to implementthis intervention is not yet clear.

When looking at the quality of thetrials included in this review, a meanscore of 6 can be considered a highscore because these trials were exer-cise trials where it is impossible toblind the treatment provider andsubjects, and, therefore, the maxi-mum PEDro score that can beachieved is 8. However, becausesome trials were of lower method-ological quality, they potentiallypresent biased (and overly optimis-tic) estimates of treatment effects.To assess the impact of the lower-quality studies on the review conclu-sions, a sensitivity analysis with ex-clusion of trials with scores lowerthan 524,64 was performed. When thelower-quality studies were deleted,the effect size unexpectedly in-creased slightly for pain and disabil-ity outcomes (we did not conduct asensitivity analysis for quality of lifebecause the exclusion of these trialswould leave only one trial in thetreatment contrast). Therefore, wedo not believe that our conclusionthat motor control exercise is effec-tive (compared with minimal inter-vention or when used as a supple-ment) is an artifact of the inclusionof low-quality trials.

This review not only includes 4 newtrials that were not included in pre-vious reviews, accounting for theaddition of 560 patients, but also al-lowed the use of a meta-analyticalapproach with the inclusion of agreater number of articles into eachtreatment contrast. The pooled re-sults of this systematic reviewshowed smaller and more-precise es-

timates of treatment effects whencompared with the pooled results ofFerreira et al.13 This differenceamong studies can be seen whenlooking, for example, at the motorcontrol exercise versus minimal in-tervention contrast. For this con-trast, Ferreira et al13 included 2 trialsand found an effect of 21 on a 0 to100 scale (95% CI32 to 9) forpain, whereas we found, based on 5trials, an effect of 14.3 (95%CI20.4 to 8.1).

Although it has been only recentlythat reviews of motor control exer-cises have been published, this typeof intervention is widely acceptedand used in the clinical field aroundthe world. Therefore, it is still crucialthat further studies in the area bedeveloped, such as a placebo-controlled trial and trials aiming toidentify subgroups of patients whowill benefit more from a motor con-trol intervention. More fundamentalstudies in LBP to establish reliableand valid clinical assessment tools toidentify deficits in motor control alsoare needed.

ConclusionThe results of this systematic reviewsuggest that motor control exerciseis more effective than minimal inter-vention and adds benefit to anotherform of intervention in reducingpain and disability for people withpersistent LBP. The optimal imple-mentation of motor control exerciseat present is unclear. Future trialsevaluating issues such as dosage pa-rameters, feedback approaches, andeffects in defined subgroups are ahigh priority.

Ms Macedo, Dr Maher, and Dr Latimer pro-vided concept/idea/research design anddata collection. Ms Macedo and Dr Maherprovided writing and data analysis. MsMacedo, Dr Maher, and Dr McAuley pro-vided project management. Dr Latimer pro-vided clerical support and consultation (in-cluding review of manuscript beforesubmission).

Ms Macedo holds a PhD scholarship jointlyfunded by The University of Sydney and theAustralian Government. Dr Mahers researchfellowship is funded by Australias NationalHealth and Medical Research Council.

This article was received April 3, 2008, andwas accepted October 10, 2008.

DOI: 10.2522/ptj.20080103

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