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Motor Control Exercise for Chronic Nonspecific Low Back Pain

Whitehead, Phyllis Brown

doi: 10.1097/NOR.0000000000000370
Cochrane Corner

Phyllis Brown Whitehead, PhD, APRN, ACHPN, RN-BC, Clinical Nurse Specialist, Palliative Medicine/Pain Management, Carilion Roanoke Memorial Hospital, and Assistant Professor, Virginia Tech Carilion School of Medicine Roanoke.

A member of the Cochrane Nursing Care Field (CNCF).

The author reports no conflict of interest.

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Objectives

To evaluate the effectiveness of motor control exercises (MCE) in patients with chronic nonspecific low back pain.

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Type of Review

The authors conducted electronic searches in CENTRAL, MEDLINE, EMBASE, five other databases, and two trials registers from their inception up to April 2015: Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 3); MEDLINE (OvidSP, 1946 to March Week 5, 2015); MEDLINE In-Process & Other Non-Indexed Citations (OvidSP, 1 April 2015); EMBASE (OvidSP, 1980 to 2015 Week 13); Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1981 to April 2015); Allied and Complementary Medicine (AMED) (OvidSP, 1985 to March 2015); SPORTDiscus (EBSCO, 1800 to April 2015); Physiotherapy Evidence Database (PEDro); Latin American and Caribbean Health Sciences Literature (LILACS); ClinicalTrials.gov; World Health Organization International Clinical Trials Registry Platform (WHO ICTRP); PubMed. They also performed citation tracking and searched the reference lists of reviews and eligible trials.

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Relevance for Nursing

Nonspecific low back pain (LBP) is a common condition. It is reported to be a major health and socioeconomic problem associated with work absenteeism, disability, and high costs for patients and society (Saragiotto et al., 2016). Exercise is a common and modestly effective treatment for chronic LBP. Therefore, nurses need to understand what evidence exists supporting the use of MCE in treating LBP, so they can advocate for the best pain management for their patients.

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Characteristics of the Evidence

The authors included randomized controlled trials up to April 2015. They examined the effectiveness of MCE in patients with chronic nonspecific LBP. The authors included trials comparing MCE with no treatment, another treatment, or that added MCE as a supplement to other interventions. They considered function, quality of life, return to work, or recurrence as secondary outcomes. All outcomes had to be measured with a valid and reliable instrument. Primary outcomes were pain intensity and disability. The authors did not consider trials with quasirandom allocation procedures for this review. The authors excluded trials evaluating Pilates.

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Summary of Key Evidence

In total, 2,431 participants were enrolled in 29 trials. The study sample sizes ranged from 20 to 323 participants, and most of them were middle-aged people recruited from primary or tertiary care. The duration of the treatment programs ranged from 20 days to 12 weeks, and the number of treatment sessions ranged from one to five sessions per week. Sixteen trials compared MCE with other types of exercises, seven trials compared MCE with minimal intervention, five trials compared MCE with manual therapy, three trials compared MCE with a combination of exercise and electrophysical agents (EPA), and one trial compared MCE with telerehabilitation based on home exercises.

Motor control exercises provided better improvements in pain, function, and global impression of recovery than minimal intervention (e.g., advice, placebo, no treatment) at all follow-up periods. Motor control exercises may provide slightly better improvements than the combination of exercise and EPA for pain, disability, global impression of recovery, and the physical component of quality of life in the short and intermediate term. There is probably little or no difference between MCE and manual therapy for all outcomes and follow-up periods. Little or no difference is observed between MCE and other forms of exercise (Saragiotto et al., 2016).

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Best Practice Recommendations

Although the quality of evidence varied among the outcomes and period investigated, the findings demonstrate that there is low to moderate quality evidence that MCE is more effective than a minimal intervention for chronic LBP. There is very low to low-quality evidence that MCE is more effective than exercise plus EPA. The authors are uncertain about the effectiveness of MCE compared with exercise and EPA, as they considered the quality of the evidence low or very low. The authors did not find a clinically important difference between MCE and manual therapy for any of the outcomes investigated, with moderate to high-quality evidence. There is low-quality evidence that there is no clinically important difference between MCE and other forms of exercise in terms of pain and disability in the short term. As MCE appears to be a safe form of exercise and none of the other types of exercise stands out, the choice of exercise for chronic LBP should depend on patient or therapist preferences, therapist training, costs, and safety (Saragiotto et al., 2016).

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Research Recommendations

Future randomized controlled trials in chronic nonspecific LBP should include more complete descriptions of the exercise interventions so that interpretation of the results would be more transparent. The authors strongly recommend that future trials have adequate sample size as most of the trials in this review are considered small (fewer than 50 participants). Trials including cost-effectiveness analysis and long-term outcomes are also needed in this area. The effectiveness of MCE should be also tested in target groups, such as subgroups of patients more likely to respond to this treatment approach (Saragiotto et al., 2016).

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Reference

Saragiotto B. T., Maher C. G., Yamato T. P., Costa L. O. P., Menezes Costa L. C., Ostelo R. W. J. G., Macedo L. G. (2016). Motor control exercise for chronic non-specific low-back pain. Cochrane Database of Systematic Reviews, 1, CD012004. doi:10.1002/14651858.CD012004
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