Low Back Pain—Is Motor Control Exercise Superior to General Exercise?

Research from the human side…relevant regardless 🙂 Rehabdeb, 3/2017

Low Back Pain—Is Motor Control Exercise Superior to General Exercise? A Review of the Research
by NSCA Personal Training Quarterly (PTQ)
and Nick Tumminello

PTQ-3.3-3 Low Back Pain—Is Motor Control Exercise Superior to General Exercise? A Review of the Research

This article provides an overview of the scientific evidence comparing specific motor control exercise intervention to using a more general exercise approach, and concludes by discussing the practical implications for strength and conditioning professionals from an exercise programming perspective.

 

Low back pain (LBP) is one of the major concerns of current healthcare. Motor control exercises, which are often referred to as “spinal stabilization” or “core stability” exercises, are often used by healthcare professionals worldwide as a common treatment for LBP.

Motor control exercises are designed for the individual to learn how to preferentially contract the local stabilizing muscles of the spine (e.g., multifidus, transversus abdominis, internal oblique) independently from the superficial trunk muscles (e.g., erector spinae rectus abdominis). Motor control exercises involve low-load activation of the local stabilizing muscles of the spine isometrically and in minimally loaded positions (e.g., four-point kneeling, supine lying, sitting, standing, etc.). A common example of a motor control exercise is the transversus abdominis draw-in. This exercise is often performed either lying supine or in four-point kneeling position and requires the individual to perform a slight drawing-in maneuver of the lower part of the anterior abdominal wall below the umbilical level (18).

Since research has shown altered recruitment patterns of deep trunk muscles, such as the transverse abdominis and lumbar multifidus in patients with LBP, these motor control exercises are often used in attempt to reestablish coordination of the deep trunk muscles in order to improve control of the spine (1,2,8,16,17).

Consequently, motor control exercises have also drawn tremendous attention from strength and conditioning professionals. Many strength and conditioning professionals often prescribe motor control exercises to their clients with current or previous LBP issues. The motor control exercises prescribed usually focus on activating the deep trunk muscles to restore control and coordination of these muscles. Many strength and conditioning professionals will often dedicate a great deal of their programming time, especially in the early stages of training, to using motor control exercises in order to first address what they believe to be the individual’s “underlying dysfunctions.” This is because a key feature of the motor control exercise approach is the training of the deep trunk muscles in isolation before progressing to demanding tasks that train coordination of the deep and the superficial trunk muscles (18). Then they will often focus the training program on the use of more general trunk training exercises, such as plank and side plank variations, which are often selected on the basis of maximizing the contraction benefit/spinal loading ratio, according to recommendations provided from recent experimental studies (15). These general trunk muscle specific-exercises will often be included into a comprehensive total-body strength and conditioning program, which often involves a variety of conventional resistance exercises such as loaded squat and deadlift variations that integrate the activation of deep and global trunk muscles along with other muscle groups (14).

Contrary to common belief, the current body of scientific evidence demonstrates that there is nothing special about using motor control exercises as a means to prevent or reduce back pain. This article provides an overview of the scientific evidence comparing specific motor control exercise intervention to using a more general exercise approach, and concludes by discussing the practical implications for strength and conditioning professionals from an exercise programming perspective.

Overview of the Evidence
An early study randomized LBP patients into two groups: a conventional physiotherapy group consisting of only general activity exercises (aimed at improving the muscular strength of the lumbar and pelvic region and legs, such as the abdominals, erector spinae, gluteals, quadriceps, and hamstrings) and manual therapy, and a conventional physiotherapy plus specific spinal stabilization exercises group (3). This study found that patients with LBP showed improvements with both treatment packages to a similar degree. Therefore, the researchers concluded that “there was no additional benefit of adding specific spinal stabilization exercises to a conventional physiotherapy package for patients with recurrent LBP,” (3).

A randomized, controlled trial of patients with recurrent, nonspecific back pain (NSLBP), compared two groups: a general exercise treatment group and a combination of general exercise and spinal stabilization exercise group. This study reported that a general exercise program reduced disability immediately after treatment to a greater extent than a stabilization-enhanced exercise approach in patients with recurrent NSLBP. However, there were no between-group differences on self-reported disability at the three-month follow-up (9). Therefore, stabilization exercises do not appear to provide additional benefit to patients with subacute or chronic LBP who have no clinical signs suggesting the presence of spinal instability (9).

Another randomized, controlled trial compared the effects of general exercise, motor control exercise, and manipulative therapy on function and perceived effect of intervention in patients with chronic back pain (6). The researchers found that “motor control exercise and spinal manipulative therapy produce slightly better short-term function and perceptions of effect than general exercise, but not better medium or long-term effects, in patients with chronic non-specific back pain,” (6).

A recent systematic review found that “evidence of very low to moderate quality indicates that motor control exercise showed no benefit over spinal manipulative therapy, other forms of exercise, or medical treatment in decreasing pain and disability among patients with acute and subacute low back pain. Whether motor control exercise can prevent recurrences of low back pain remains uncertain,” (11).

Additionally, another systematic review, this one about chronic NSLBP, concluded that “there is very low to moderate quality evidence that motor control exercise has a clinically important effect compared with a minimal intervention for chronic low back pain. There is moderate to high quality evidence that motor control exercise provides similar outcomes to manual therapies and low to moderate quality evidence that it provides similar outcomes to other forms of exercises,” (21). The authors went on to say that motor control exercises are not necessarily superior to other forms of exercise, and that the choice of exercises for chronic LBP should depend on individual preferences, therapist training, costs, and/or safety concerns (21).

Evidence Using Subgroups
Many healthcare providers state that low back pain is a multidimensional, socioeconomic public health problem with almost 85% of patients being diagnosed with NSLBP (4,7,10,12,13,22,23). They will also likely readily admit that treating chronic LBP is complicated because neither specific diagnostic nor treatment-based approaches have been shown to be absolutely effective. Many practitioners often prescribe motor control exercises almost universally to people with LBP issues. One of the common concerns many health rehabilitation specialists and strength and conditioning professionals who promote the use of specific motor control exercise interventions have with the research discussed above is that those studies did not involve patient subgroups. These professionals believe that patients with a motor control impairment can be diagnosed as a LBP subgroup who would benefit from specific motor control exercises. Therefore, they encourage studies in such patient subgroups with a common diagnosis or prognosis to examine outcomes from specific motor control exercise interventions.

To meet this concern, a recent study used a tailored exercise program versus general exercise for a subgroup of patients with LBP and movement control impairment. This study assessed the short-term effect of a specific exercise program targeting movement control impairment versus general exercise treatment on disability in patients with LBP and motor control impairment.

At the conclusion of this study, “no significant difference was found following the treatment period. Disability in LBP patients was reduced considerably by both interventions,” (20).

Another randomized controlled trial study that also involved subacute or chronic low-back pain patient subgroups found that motor control exercise and general exercise appear equally effective at reducing LBP in the patient subgroup included in this study (19). The researchers concluded that “the contrast between both types of intervention did not bring additional value to the shared effects,” (19). Additionally, strength and conditioning professionals should pay special attention to the following statements from the researchers of this study: “it is possible that the type of exercise treatment is less important than previously presumed; that the patient is guided to a consistent long-term exercise lifestyle is of most importance. The results of our study support previous findings that exercise in general, regardless of the type, is beneficial for patients with NSLBP,” (19).

Conclusion and Practical Takeaway
The overall takeaway of these studies is that exercise is a moderately effective treatment for chronic LBP. Although moderate evidence suggests that special motor control exercise interventions may prevent recurrences of LBP, no good evidence has been found for a difference in effect between types of exercise. In other words, although special motor control exercise interventions have been shown to improve low back outcomes, these exercises do not appear to be any more beneficial than general exercises, which also offer a wide range of well-established health, fitness, and physique benefits. Therefore, when it comes to clients with LBP, the strength and conditioning professional should not be hesitant to focus their programming on the use of general exercises that fit with the individual’s ability, medical profile, and personal goals.

This article originally appeared in Personal Training Quarterly (PTQ)—a quarterly publication for NSCA Members designed specifically for the personal trainer. Discover easy-to-read, research-based articles that take your training knowledge further with Nutrition, Programming, and Personal Business Development columns in each quarterly, electronic issue. Read more articles from PTQ »

Related Reading
Systematic Review of Core Muscle Activity During Physical Fitness Exercises

References
1. Al-Eisa, E, Egan, D, Deluzio, K, and Wassersug, R. Effects of pelvic skeletal asymmetry on trunk movement three-dimensional analysis in healthy individuals versus patients with mechanical low back pain. Spine 31(3): E71-79, 2006.
2. Bogduk, N. Management of chronic low back pain. The Medical Journal of Australia. 180)(2): 79-83, 2004.
3. Cairns, MC, Foster, NE, and Wright, C. Randomized controlled trial of specific spinal stabilization exercises and conventional physiotherapy for recurrent low back pain. Spine 31(19): E670-681, 2006.
4. Champagne, A, Descarreaux, M, and Lafon, D. Comparison between elderly and young males’ lumbopelvic extensor muscle endurance assessed during a clinical isometric back extension test. Journal of Manipulative and Physiological Therapeutics 32(7): 521526, 2009.
5. Choi, B, Verbeek, JH, Tam, WW, and Jiang, JY. Exercises for prevention of recurrences of low-back pain. Cochrane Database of Systematic Reviews 20(1): 2010.
6. Ferreira, ML, Ferreira, PH, Latimer, J, Herbert, RD, Hodges, PW, Jennings, MD, et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial. Pain 131(1-2): 31-37, 2007.
7. Gondhalekar, GA, Kumar, SP, Eapen, C, Mahale, A. Reliability and validity of standing back extension test for detecting motor control impairment in subjects with low back pain. Journal of Clinical and Diagnostic Research. 10(1): KC7-11, 2016.
8. Harris-Hayes, M, Van Dillen, LR, and Sahrmann, SA. Classification, treatment and outcomes of a patient with lumbar extension syndrome. Physiotherapy Theory and Practice 21(3): 181-96, 2005.
9. Koumantakis, GA, Watson, PJ, and Oldham, JA. Trunk muscle stabilization training plus general exercise versus general exercise only: Randomized controlled trial of patients with recurrent low back pain. Physical Therapy 85(3): 209-225, 2005.
10. Luomajoki, H, Kool, J, de Bruin, ED, and Airaksinen, O. Reliability of movement control tests in the lumbar spine. BioMed Central Musculoskeletal Disorders 8: 90, 2007.
11. Macedo, LG, Saragiotto, BT, Yamato, TP, Costa, LOP, Costa, LCM, Ostelo, RWJG, and Maher, CG. Motor control exercise for acute non-specific low back pain. Cochrane Database of Systematic Reviews CD012085, 2016.
12. Maher, CG, Latimer, J, Hodges, PJ, Refshauge, KM, Moseley, GL, Herbert, RD, et al. The effect of motor control exercise versus placebo in patients with chronic low back pain. BioMed Central Musculoskeletal Disorders 6: 54, 2005.
13. Manchikanti, L. Epidemiology of low back pain. Pain Physician. 3(2): 167-192, 2000.
14. Martuscello, JM, et al. Systematic review of core muscle activity during physical fitness exercises. The Journal of Strength and Conditioning Research 27(6): 1684-1698, 2013.
15. McGill, SM. Low back exercises: evidence for improving exercise regimens. Physical Therapy 78(7): 754-765, 1998.
16. O’Sullivan, PB. Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism. Manual Therapy 10(4): 242255, 2005.
17. O’Sullivan, PB. Lumbar segmental “instability:” Clinical presentation and specific stabilizing exercise management. Manual Therapy 5(1): 2-12, 2000.
18. Richardson, CA, Jull, GA, and Hodges, PW, et al. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain. Edinburgh: Churchill Livingstone, 1999.
19. Saner, J, Kool, J, Sieben, JM, Luomajoki, H, Bastiaenen, CHG, and de Bie, RA. A tailored exercise program versus general exercise for a subgroup of patients with low back pain and movement control impairment: A randomised controlled trial with one-year follow-up. Manual Therapy 20(5): 672-279, 2015.
20. Saner, J, Sieben, JM, Kool, J, Luomajoki, H, Bastiaenen, CHG, and de Bie, RA. A tailored exercise program versus general exercise for a subgroup of patients with low back pain and movement control impairment: Short-term results of a randomised controlled trial. Journal of Bodywork Movement Therapies 20(1): 189-202, 2015.
21. Saragiotto, BT, Maher, CG, Yamato, TP, Costa, LOP, Costs, LCM, Ostelo, RWJG, and Macedo, LG. Motor control exercise for chronic non-specific low-back pain. Cochrane Database of Systematic Reviews CD012004, 2016.
22. Tétreau, C, Dubois, JD, Piché, M, and Descarreaux, M. Modulation of pain-induced neuromuscular trunk responses by pain expectations: A single group study. Journal of Manipulative and Physiological Therapeutics 35(8): 636-644, 2012.
23. Tidstrand, J, and Horneji, E. Inter-rater reliability of three standardized functional tests in patients with low back pain. BioMed Central Musculoskeletal Disorders 10: 58, 2009.

Nick Tumminello
About the Author:
Nick Tumminello, NSCA-CPT
Nick Tumminello has become known as “the trainer of trainers.” He is the owner of Performance University, which provides fitness and personal trainer continuing education. Tumminello is a fitness expert for Reebok and the author of the book “Strength Training for Fat Loss.” He lives in Fort Lauderdale, FL, where he trains a select group of individuals and teaches mentorships. His DVDs, books, seminar schedule, and blog can be found at PerformanceU.net.

Warm Up More Productive Than Stretching to Avoid Injuries

Warm up More Productive Than Stretching-

I’ve read studies on the topic of stretching for several decades and the consistent evidence is as Dr. Mirkin presents it (below).

Every opportunity I get to work with competitive dogs is an opportunity to reeducate the human clients about sport training and competition. People in the pet competition world often promote ball stretching as an acceptable form of pre-competition warm up or exercise.

Ball stretching before an event is more destructive than helpful. Coming out of a crate and trotting around just a short bit is not enough of a warm up prior to competition. Dogs should do better in events with at least a quarter-mile slow jog warm up and then a few sprints. This would also be beneficial prior to training drills as well. Just the basics…

The article below comes from Dr. Gabe Mirkin’s Fitness and Health e-Zine
April 7, 2013

Stretching Before Exercising Provides Only Flexibility

Whenever I see someone stretching before running, cycling, tennis, swimming, or any other sport, I worry that the person doesn’t know much about training.

Exercise First and Then Stretch

Stretching Before Exercise Only Weakens Muscles:

Two recent studies show that stretching before competition and training weakens muscles. Stretching prevents you from lifting your heaviest weights or running your fastest miles. It limits how high you can jump, and how fast you can run (The Journal of Strength and Conditioning Research. April, 2013; The Scandinavian Journal of Medicine and Science in Sports, April, 2013).

Stretching weakens muscles by almost 5.5 percent. The longer you hold the stretch, the more strength you lose. Holding a stretch for more than 90 seconds markedly reduces strength in that muscle. Stretching reduces power: how hard you can hit a baseball or tennis ball, how fast you can swim, run or pedal, Stretching also does not prevent next-day muscle soreness, and it does not prevent injuries. On the other hand, warming up helps to prevent injuries and helps you to run faster and lift heavier.

Rudi Stretching Naturally After Exercise
Rudi the Brittany Spaniel in Rehab After Hip Surgery, FHO, Femoral Head Osteotomy. He’s Doing Natural Stretching AFTER exercise, and NOT Doing Forced Range of Motion Work by His Mom Owner

 

How Muscles Move Your Body:

Every muscle in your body is made up of thousands of individual fibers. Each fiber is composed of sarcomeres, repeated similar blocks, lined end-to-end to form the rope-like fibers. Each sarcomere touches the sarcomere next to it at the Z line. Muscles move your body by contracting, a shortening of each muscle fiber. Muscles do not shorten (contract) equally throughout their lengths. Muscles contract only at each of thousands of Z lines. It is the cumulative shortening of thousands of Z lines that shorten fibers to make muscles contract and move your body.

How Stretching Saps Strength:

When you stretch a muscle, you pull on the muscle fibers and stretch apart each fiber at the thousands of Z lines. This damage occurs only at the Z lines throughout the length of the muscle fiber, to weaken the entire muscle.

Prolonged Stretching Limits the Ability of Muscles to Store Energy:

Muscles are like rubber bands. They stretch and contract with each muscle movement. This constant stretching and contracting stores energy. For example, when you run, you land on your foot and the muscle stops contracting suddenly.

The force of your foot striking the ground is stored in your muscles and tendons and this energy is released immediately to drive you forward. Your foot hits the ground with a force equal to three times your body weight when you run at a pace of six minutes per mile. Up to 70 percent of the force of your foot strike is stored in your Achilles and other tendons. This energy is released by your muscles and tendons to drive you forward for your next step.

Stretching decreases the amount of energy you can store in muscles and tendons and therefore weakens you and you have less stored energy to drive you forward, so you have to slow down.

Stretching Saps Speed and Endurance:

Elite college sprinters were timed in 20 meter sprints, with and without prior multiple 30-second stretches of their leg muscles. Both active and passive stretching slowed them down (Journal of Sports Science, May 2005).

Stretching Does Not Prevent Next Day Muscle Soreness:

A review of 12 studies published over the last 25 years shows that stretching does not prevent muscle soreness that occurs 8 to 24 hours after you exercise vigorously (The British Journal of Sports Medicine, December 2011; 45:15 1249-1250). Researchers in Australia reviewed five studies, involving 77 subjects, to show that stretching does not prevent next-day muscle soreness. (British Medical Journal. December 2007; 325:468-70 and 451-2).

Stretching Does Not Prevent Injuries:

A review of the scientific literature shows that there is no good evidence that stretching prevents sports injuries (Clinical Journal of Sports Medicine. March 2005). Muscles and tendons tear when the force applied to them is greater than their inherent strength, so anything that makes a muscle stronger helps to prevent injuries. Strengthening muscles helps prevent muscle and tendon tears, but stretching does not make muscles stronger. This review showed that stretching does not prevent shin splints, bone stress fractures, sprains, strains or other arm and leg injuries.

 

Original Post August 3, 2014. Updated February 19, 2018