Treatment preference changes after exposure to treatment in adults with chronic low back pain.

BACKGROUND: Patients' pretreatment preferences can influence outcomes of nonpharmacologic treatments for musculoskeletal pain. Less is known about how patients' treatment preferences change following exposure to treatment. OBJECTIVE: To examine the effect of exposure to treatment and change in disability and pain on treatment preference ratings of two exercise-based treatments for people with chronic low back pain (LBP). DESIGN: Secondary analysis of a subsample of participants from a randomized clinical trial. SETTING: Academic research setting. PARTICIPANTS: Individuals with chronic LBP (n = 83). INTERVENTIONS: 6 weekly sessions of motor skill training (MST) or strength and flexibility exercise (SFE). MAIN OUTCOME MEASURES: Prior to treatment, participants completed a treatment preference assessment measure (TPA) describing MST and SFE. Participants rated four attributes (effectiveness, acceptability/logicality, suitability/appropriateness, convenience) of each treatment on a 5-point Likert scale (0-4) with higher scores indicating higher ratings. An overall preference rating was calculated as the mean of the attribute ratings. The TPA was administered 12 months post treatment to reassess participants' ratings of the treatment they received. RESULTS: Participants who received MST rated their preference for MST higher 12 months post treatment and participants who received SFE rated their preference for SFE lower. Smaller improvements (to worsening) in pain were associated with a reduction in preference ratings in the SFE group, whereas the MST group generally increased their ratings regardless of pain. Changes in disability were not related to changes in preference ratings. CONCLUSIONS: Participants changed their preference ratings of two exercise-based treatments for LBP after exposure to the treatment. Participants who received the less familiar MST viewed this treatment more favorably 12 months post treatment, and this change was less contingent on changes in disability/pain than for participants in the SFE group. Assessing preference ratings at various times during treatment is crucial to understand a person's preference for and perceptions of a treatment.

Motor skill training versus strength and flexibility exercise in people with chronic low back pain: Preplanned analysis of effects on kinematics during a functional activity.

BACKGROUND: People with chronic low back pain display the altered movement pattern where the lumbar spine moves more readily into its available range of motion relative to other joints. A logical approach to treatment, therefore, would be to improve this pattern during functional activities. METHODS: 154 participants were randomized to receive 6 weeks of motor skill training or strength and flexibility exercise. Participants in the motor skill training group received person-specific training to modify their altered movement pattern during functional activities. Participants in the strength and flexibility group received exercises for trunk strength and trunk and lower-limb flexibility. At baseline, post-treatment and 6-months after treatment participants performed a test of picking up an object using their preferred pattern. Three-dimensional marker co-ordinate data were collected. A mixed-model repeated measures analysis of variance was used to examine the treatment group and time effects. FINDINGS: Motor skill training: Baseline early excursion values [mean (confidence interval)] were as follows: knee = 11.1°(8.0,4.1), hip = 21.2°(19.2,23.1), lumbar = 11.3°(10.4,12.3). From baseline to post-treatment significant improvements in early excursion included: knee = +18.6°(15.4,21.8), hip = +10.8°(8.8,12.8), and lumbar = -2.0°(-0.1,-4.0). There were no significant changes from post-treatment to 6-month follow-up. Strength and flexibility exercise: Baseline early excursion values were as follows: knee = 8.9°(5.8,11.9), hip = 20.8°(18.9,22.8), and lumbar = 11.2°(10.3,12.2) early excursion. There were no significant changes for knee, hip, and lumbar early excursion. INTERPRETATION: Motor skill training was more effective than strength and flexibility exercise at changing and maintaining change to the altered movement pattern during a functional activity test of picking up an object.

Consistent differences in lumbar spine alignment between low back pain subgroups and genders during clinical and functional activity sitting tests.

BACKGROUND: Subgroups of people with low back pain display differences in their lumbar alignment during tests from a clinical examination. However, it is unknown if subgroups display the same patterns during a functional activity test and if gender influences subgroup-related differences. OBJECTIVES: Test if differences in lumbar alignment between two LBP subgroups are 1) present during a functional activity test of preferred sitting and 2) independent of gender. DESIGN: Cross-sectional. METHOD: 154 participants with chronic low back pain were classified based on the Movement System Impairment Classification System by a physical therapist. Participants performed a functional activity test of preferred sitting and clinical tests of maximum flexed and extended sitting. 3D marker co-ordinate data were collected. Sagittal plane lumbar alignment, indexed by lumbar curvature angle, was calculated. A three-way mixed effect analysis of variance was used to examine effects of test, subgroup, gender, subgroup × test, gender × test and subgroup × gender. RESULTS/FINDINGS: The lumbar rotation with extension subgroup [LCA = -8.0° (-9.5,-6.5)] displayed a more extended lumbar alignment than lumbar rotation [LCA = -5.9° (-7.4,-4.4)]. Women [LCA = -10.7° (-12.3,-9.2)] displayed a more extended lumbar alignment than men [LCA = -3.2° (-4.7,-1.7)]. There was a significant gender × test interaction (p = 0.01). The subgroup × test (p = 0.99) and subgroup × gender (p = 0.76) interactions were not significant. CONCLUSIONS: LBP subgroup differences in lumbar alignment are present during preferred sitting. Gender-related differences in lumbar alignment are not driving subgroup differences. These findings highlight the need to use patient-specific clinical characteristics to guide treatment of a functional activity of preferred sitting limited due to low back pain.

Effect of Motor Skill Training in Functional Activities vs Strength and Flexibility Exercise on Function in People With Chronic Low Back Pain: A Randomized Clinical Trial.

Importance: Chronic low back pain (LBP) is the most prevalent chronic pain in adults, and there is no optimal nonpharmacologic management. Exercise is recommended, but no specific exercise-based treatment has been found to be most effective. Objective: To determine whether an exercise-based treatment of person-specific motor skill training (MST) in performance of functional activities is more effective in improving function than strength and flexibility exercise (SFE) immediately, 6 months, and 12 months following treatment. The effect of booster treatments 6 months following treatment also was examined. Design, Setting, and Participants: In this single-blind, randomized clinical trial of people with chronic, nonspecific LBP with 12-month follow-up, recruitment spanned December 2013 to August 2016 (final follow-up, November 2017), and testing and treatment were performed at an academic medical center. Recruitment was conducted by way of flyers, physician and physical therapy offices, advertisements, and media interviews at Washington University in St Louis, Missouri. Of 1595 adults screened for eligibility, 1301 did not meet the inclusion criteria and 140 could not be scheduled for the first visit. A total of 154 people with at least 12 months of chronic, nonspecific LBP, aged 18 to 60 years, with modified Oswestry Disability Questionnaire (MODQ) score of at least 20% were randomized to either MST or SFE. Data were analyzed between December 1, 2017, and October 6, 2020. Interventions: Participants received 6 weekly 1-hour sessions of MST in functional activity performance or SFE of the trunk and lower limbs. Half of the participants in each group received up to 3 booster treatments 6 months following treatment. Main Outcomes and Measures: The primary outcome was the modified Oswestry Disability Questionnaire (MODQ) score (0%-100%) evaluated immediately, 6 months, and 12 months following treatment. Results: A total of 149 participants (91 women; mean [SD] age, 42.5 [11.7] years) received some treatment and were included in the intention-to-treat analysis. Following treatment, MODQ scores were lower for MST than SFE by 7.9 (95% CI, 4.7 to 11.0; P < .001). During the follow-up phase, the MST group maintained lower MODQ scores than the SFE group, 5.6 lower at 6 months (95% CI, 2.1 to 9.1) and 5.7 lower at 12 months (95% CI, 2.2 to 9.1). Booster sessions did not change MODQ scores in either treatment. Conclusions and Relevance: People with chronic LBP who received MST had greater short-term and long-term improvements in function than those who received SFE. Person-specific MST in functional activities limited owing to LBP should be considered in the treatment of people with chronic LBP. Trial Registration: ClinicalTrials.gov Identifier: NCT02027623.

Motor skill training in musculoskeletal pain: a case report in chronic low back pain.

Purpose: Low back pain is a chronic condition that limits function. The chief reason individuals with low back pain seek care is difficulty performing functional activities. A novel approach to improving performance of painful and limited functional activities is motor skill training, defined as challenging practice of activities to learn or relearn a skill. The purpose of this report is to describe the design and application of a motor skill training intervention in a 26-year-old man with a 10-year history of low back pain. Methods: A motor skill training intervention was implemented to modify the altered alignment and movement patterns he used during the performance of his painful and limited activities. Results: The patient was seen for six visits in 12 weeks. The patient reported decreased pain and medication use, as well as improved function immediately, 3-, and 9-months post-intervention. Conclusion: Individuals with low back pain report limitation in ability to perform everyday functions and demonstrate altered patterns of movement and alignment during these activities. This case report describes an innovative motor skill training intervention that directly addresses the performance of functional activities and the application of motor learning principles. Implications for rehabilitation Low back pain is a chronic condition that limits function. The chief reason individuals with chronic low back pain seek care is difficulty performing everyday functional activities. Motor skill training is a novel approach that directly addresses the performance of painful and limited functional activities through challenging practice to improve performance and decrease pain.

A Cross-Sectional Study Assessing Treatment Preference of People With Chronic Low Back Pain.

OBJECTIVE: To assess treatment preference and attributes of 2 exercise-based treatments for people with chronic low back pain (LBP). DESIGN: Cross-sectional study. SETTING: Academic research setting. PARTICIPANTS: Individuals (N=154) with chronic LBP. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants completed a treatment preference assessment (TPA) measure that described 2 treatments for chronic LBP (strength and flexibility [SF] and motor skill training [MST]). Participants rated each treatment on 4 attributes: effectiveness, acceptability/logicality, suitability/appropriateness, and convenience. An overall score for each treatment was calculated as the mean of the 4 attribute ratings. The participants indicated either (1) no treatment preference or (2) preference for SF or MST. RESULTS: One hundred four participants (67.5%) had a treatment preference; of those, 95 (91.3%) preferred SF and 9 (8.7%) preferred MST. The SF preference group rated SF higher than MST overall and on all attributes (all Ps <.01, ds ranged from .48-1.07). The MST preference group did not rate the treatments differently overall or on any of the attributes (all Ps >.05, ds ranged from .43-.66). Convenience of SF (P=.05, d=.79) and effectiveness (d=1.20), acceptability/logicality (d=1.27), and suitability/appropriateness (d=1.52) of MST (all Ps <.01) were rated differently between the 2 preference groups. CONCLUSIONS: When presented with 2 treatment options, a majority of patients preferred SF over MST. Convenience was a particularly important attribute affecting preference. Assessing treatment preference and attributes prior to treatment initiation allows the clinician to identify factors that may need to be addressed to enhance adherence to, and outcomes of, treatment.

Immediate Effects of a Single Session of Motor Skill Training on the Lumbar Movement Pattern During a Functional Activity in People With Low Back Pain: A Repeated-Measures Study.

Background: People with low back pain (LBP) may display an altered lumbar movement pattern of early lumbar motion compared to people with healthy backs. Modifying this movement pattern during a clinical test decreases pain. It is unknown whether similar effects would be seen during a functional activity. Objective: The objective of this study was to examine the lumbar movement patterns before and after motor skill training, effects on pain, and characteristics that influenced the ability to modify movement patterns. Design: The design consisted of a repeated-measures study examining early-phase lumbar excursion in people with LBP during a functional activity test. Methods: Twenty-six people with chronic LBP received motor skill training, and 16 people with healthy backs were recruited as a reference standard. Twenty minutes of motor skill training to decrease early-phase lumbar excursion during the performance of a functional activity were used as a treatment intervention. Early-phase lumbar excursion was measured before and after training. Participants verbally reported increased pain, decreased pain, or no change in pain during performance of the functional activity test movement in relation to their baseline pain. The characteristics of people with LBP that influenced the ability to decrease early-phase lumbar excursion were examined. Results: People with LBP displayed greater early-phase lumbar excursion before training than people with healthy backs (LBP: mean = 11.2°, 95% CI = 9.3°-13.1°; healthy backs: mean = 7.1°, 95% CI = 5.8°-8.4°). Following training, the LBP group showed a decrease in the amount of early-phase lumbar excursion (mean change = 4.1°, 95% CI = 2.4°-5.8°); 91% of people with LBP reported that their pain decreased from baseline following training. The longer the duration of LBP (ß = - 0.22) and the more early-phase lumbar excursion before training (ß = - 0.82), the greater the change in early-phase lumbar excursion following training. Limitations: The long-term implications of modifying the movement pattern and whether the decrease in pain attained was clinically significant are unknown. Conclusions: People with LBP were able to modify their lumbar movement pattern and decrease their pain with the movement pattern within a single session of motor skill training.