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Does it Matter Which Exercise?: A Randomized Control Trial of Exercise for Low Back Pain

Long, Audrey BScPT*; Donelson, Ron MD†; Fung, Tak PhD‡

doi: 10.1097/01.brs.0000146464.23007.2a
Randomized Trial

Study Design. Multicentered randomized controlled trial.

Objectives. To determine if previously validated low back pain (LBP) subgroups respond differently to contrasting exercise prescriptions.

Summary of Background Data. The role of “patient-specific” exercises in managing LBP is controversial.

Methods. A total of 312 acute, subacute, and chronic patients, including LBP-only and sciatica, underwent a standardized mechanical assessment classifying them by their pain response, specifically eliciting either a “directional preference” (DP) (i.e., an immediate, lasting improvement in pain from performing either repeated lumbar flexion, extension, or sideglide/rotation tests), or no DP. Only DP subjects were randomized to: 1) directional exercises “matching” their preferred direction (DP), 2) exercises directionally “opposite” their DP, or 3) “nondirectional” exercises. Outcome measures included pain intensity, location, disability, medication use, degree of recovery, depression, and work interference.

Results. A DP was elicited in 74% (230) of subjects. One third of both the opposite and non-directionally treated subjects withdrew within 2 weeks because of no improvement or worsening (no matched subject withdrew). Significantly greater improvements occurred in matched subjects compared with both other treatment groups in every outcome (P values <0.001), including a threefold decrease in medication use.

Conclusions. Consistent with prior evidence, a standardized mechanical assessment identified a large subgroup of LBP patients with a DP. Regardless of subjects’ direction of preference, the response to contrasting exercise prescriptions was significantly different: exercises matching subjects’ DP significantly and rapidly decreased pain and medication use and improved in all other outcomes. If repeatable, such subgroup validation has important implications for LBP management.

A multicentered randomized controlled trial targeted a validated low back pain subgroup characterized by a favorable pain response (centralization) occurring with a single direction (“directional preference”) of lumbar test movements (flexion, extension, or lateral testing). Those treated with unidirectional exercises matching their test findings reported significant improvement compared with two contrasting exercise protocols.

From *Bonavista Physical Therapy, Calgary, Alberta, Canada; †SelfCare First, Hanover, NH; and ‡Department of Psychology, University of Calgary, Calgary, Alberta, Canada.

Supported by the Community Ethics Review Board of the Alberta Heritage Foundation for Medical Research, the Physiotherapy Foundation of Canada, McKenzie Institute International, and Cambridge Physiotherapy Associates.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Foundation funds were received to support this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint requests to Audrey Long, BScPT, 620 Willesden Dr. S.E., Calgary, Alberta, Canada, T2J 2G1; E-mail:

© 2004 Lippincott Williams & Wilkins, Inc.