Motor skill training outperforms strength and flexibility exercise for lower back pain

Person-specific motor skill training (MST) is more effective in improving function than strength and flexibility exercise (SFE), a randomized clinical trial in 149 participants with chronic nonspecific lower back pain (LBP) has shown.

Chronic LBP is the most prevalent chronic pain in adults, with no established optimal nonpharmacologic management. [Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC 2011] While exercise is viewed as effective and is recommended as a first-line treatment by most clinical practice guidelines, there is limited evidence regarding the best type of exercise and the long-term effects of different exercise-based treatments. [Ann Intern Med 2005;142:765-775; Eur Spine J 2011;20:19-39; J Clin Med 2019;8:E1063]

Study participants were 18–60 years of age, had chronic LBP for ≥12 months, had limitations in at least three functional activities due to LBP, were experiencing LBP but were not in an acute flare-up at the time of study participation, and had a modified Oswestry Disability Questionnaire (MODQ) score of ≥20 percent. [JAMA Neurol 2020, doi:10.1001/jamaneurol.2020.4821]

The MST evaluated in the study involved supervised, massed practice of challenging functional activities that were difficult to perform because of LBP, with the participants choosing specific activities. “Emphasis was on changing the altered movements and alignments relevant to the person-specific classification during activities to reduce LBP. The primary treatment principles were to teach the participant to move the lumbar spine later and reduce the amount of lumbar spine movement related to their LBP classification [eg, flexion], increase use of other joints [eg, hips], and avoid end-range positioning of the lumbar spine in specific directions related to the patient’s LBP classification,” explained the researchers. On the other hand, SFE focused on improving the strength of all trunk muscles and improving trunk and lower limb flexibility in all planes.

Following treatment, the primary endpoint of MODQ scores was lower for MST than SFE by 7.9 percent (95 percent confidence interval [CI], 4.7 to 11.0; p<0.001). During the 12-month follow-up phase, the MST group maintained lower MODQ scores than the SFE group, with a 5.6 percent lower score at 6 months (95 percent CI, 2.1 to 9.1) and 5.7 percent lower score at 12 months (95 percent CI, 2.2 to 9.1).

Many of the secondary outcomes also showed statistically significant differences in favour of MST vs SFE. “MST resulted in higher satisfaction with care, greater improvement in average and worst LBP and physical function, less LBP-related medication use, less absenteeism from usual activities, and lower work-related fear avoidance beliefs compared with SFE,” wrote the researchers. “Six months after treatment, MST also resulted in fewer and shorter acute LBP flare-ups and greater adherence compared with SFE.”