Patients with chronic low back pain often have a low quality of life and treatments are not very successful. Although the strong association between psychosocial factors and persistent back pain, and the correspondingly weak association between structural abnormalities and persistent pain are both well established and widely acknowledged, treatment still focusses on the back. ‘Back exercises’ seem to help – a bit – but this is probably more due to the exercise, than anything to do with the back. There is little evidence that any specific back exercise is better.
A trial that was started in December 2013, recruited up to August 2016 and finished data collection is November 2017 has finally, on December 28th 2020, been published. It compared ‘back exercises’ with ‘motor skill training’ that was defined as “massed practice of challenging functional activities that were difficult to perform because of LBP“. Both intervention involved the patient in eight hours of training, and patients were instructed to continue training at home. Booster session were given to a random half, but did not alter the outcome. Follow-up was at one year.
The primary finding was that motor skills training was associated with a statistically and clinically significant reduction in functional disability (the modified Oswestry Disability Scale) at one year.
It took nearly three years to recruit 154 people, suggesting very strict inclusion criteria and/or a demanding intervention. Indeed the criteria were relaxed during the trial. This raises questions about generalisability.
The treatment intervention is meticulously described in a supplement. From this, I suspect that another challenge to generalisability is the detailed assessment of back movements involved in the protocol. The detail also poses a challenge to reproducibility of the treatment.
In the trial two of the authors gave all the treatment. Although not stated, I assume that each author gave both types of treatment – if not, then it might have been the therapist’s enthusiasm or personality that accounted or the difference.
One explanation for the success leads to one possible conclusion. In almost all rehabilitation practice, repeated practice of wanted activities leads to improvement in those activities practiced. The principle of this treatment was to ‘practice’ the trunk movements most associated with pain. This practice would be expected to improve function.
Moreover, as a second principle, one way to overcome any fear is to expose oneself to the fearful stimulus. In this case, the fear related to particular movements. Or, perhaps more accurately, the therapist’s assessment identified movement that were most likely to cause pain, and the patient then recognised that only certain movements caused his or her pain. Repeated practice of the movement under instruction may well have reduced fear and thereby improved function.
The take home message may be:
- with your patient, identify activities that are more likely to cause pain
- set about practicing those activities repeatedly, gradually increasing the amounts
This approach needs confirmation in a large trial with very broad intake of patients – anyone without obvious ‘red flags’ – comparing motor skill training with simple exercise, back exercise or walking.