Are Work Demand, Support and Control Associated with Work Ability and Disability during Back Pain Treatment? A Prospective Explorative Study.

BACKGROUND: Low back pain is a multifactorial disease with consequences for work ability and social participation. Improved integration of the work domain in health care management is needed. The aim of this study was to explore the relation between working conditions with outcome of low back pain treatment. METHODS: Observational study of 41 patients attending physiotherapy for low back pain. Work demands, support and control were registered at baseline and work ability and disability also at baseline, with follow up after three and nine months. We used mixed-effects models to estimate the longitudinal associations between working conditions and outcome. RESULTS: Higher work demands were related to reduced work ability (-1.1 points, 95% CI: -2.1 to -0.1) and slightly increased disability (5.6 points, 95% CI: 0.5 to 10.7). Lack of social support from colleagues was associated with reduced work ability (-2.7 points, 95% CI: -0.2 to 1.5) and disability (14.0 points, 95% CI: 4.9 to 23.1). CONCLUSIONS: This explorative study found associations between work demands and support, and work ability and disability outcome. Screening for psychosocial working conditions may influence the work ability and disability treatment outcome. The results need replication in larger samples and may indicate that patients seeking primary care management for low back pain should be screened for work demands, support and control.

Building therapeutic alliances with patients in treatment for low back pain: A focus group study.

BACKGROUND AND PURPOSE: Low back pain is a multidimensional disorder and a biopsychosocial management approach is recommended. However, recent data indicates that physiotherapists mainly focus on biomechanical aspects in treatment and struggle with addressing psychosocial barriers for recovery. We wanted to explore how physiotherapists express their experiences of building therapeutic alliances within a biopsychosocial perspective of low back pain. METHODS: Qualitative focus-group interviews were performed with five physiotherapists on two occasions with 6 months in between. Data were analyzed within a hermeneutical perspective with decontextualization and recontextualization, and identification of themes. RESULTS: Four main themes were identified from the analyses: (1) An ideal standard: Presence, empathy and applying the biopsychosocial perspective is central for building therapeutic alliance. (2) Time-consuming: Active listening and personally adapted treatment is important and time-consuming. (3) Challenging area: Advanced clinical reasoning is needed to understand and modify complex barriers for recovery. Clinical experience is sometimes necessary to integrate the psychological and social domains into physiotherapy management. (4) The art of balancing: Important to apply sensitive communication to help patients gain new insight. Some heavy psychosocial demands on patients may be outside physiotherapists' professional competence. DISCUSSION: The physiotherapists in this focus group study expressed a shared view that therapeutic alliance should build upon person-centering, motivational communication, and facilitation of lifestyle adjustments within a biopsychosocial perspective of low back pain. Complex clinical reasoning necessary as the optimal cause-corrective treatment strategies were often not obvious. Time and tools to uncover and modify relevant psychological obstacles for recovery were perceived challenging and partly dependent on clinical experience. Addressment of psychosocial obstacles for recovery should be included in basic as well as postgraduate curriculums for physiotherapists. Collaborative practice support strategies like peer guidance and better platforms for interprofessional collaboration and decision support could contribute to improve practice in the psychosocial domain.

Therapeutic Alliance: Patients' Expectations Before and Experiences After Physical Therapy for Low Back Pain-A Qualitative Study With 6-Month Follow-Up.

OBJECTIVE: The aim of this study was to explore patients' expectations before and experiences after physical therapy for low back pain. METHODS: Qualitative in-depth, semi-structured interviews with patients attending physical therapy were performed before, immediately after, and 6 months after treatment. Data were analyzed from a hermeneutical perspective with decontextualization, recontextualization, and identification of themes. RESULTS: Patients' pretreatment expectations to physical therapy focused around exercises and a body-oriented diagnosis. After treatment, reassurance, active listening with explanations, and personally adapted strategies for self-managing pain and regaining control over everyday activity were expressed as decisive for a meaningful therapeutic alliance. CONCLUSION: Expectations before treatment focused on exercises and diagnosis. Empathetic and personally adapted education aimed at empowerment was experienced as a meaningful aspect of the therapeutic alliance after treatment. The therapeutic alliance provided a basis to integrate knowledge on the complexity of pain. IMPACT: Our findings indicate that patients emphasize physical therapists' interactional and pedagogical skills as meaningful aspects of the therapeutic alliance, which has implications for clinical practice and training physical therapist students.

Prognostic ability of STarT Back Screening Tool combined with work-related factors in patients with low back pain in primary care: a prospective study.

OBJECTIVE: Primary care screening tools for patients with low back pain may improve outcome by identifying modifiable obstacles for recovery. The STarT Back Screening Tool (SBST) consists of nine biological and psychological items, with less focus on work-related factors. We aimed at testing the prognostic ability of SBST and the effect of adding items for future and present work ability. METHODS: Prospective observational study in patients (n=158) attending primary care physical therapy for low back pain. The prognostic ability of SBST and the added prognostic value of two work items; expectation for future work ability and current work ability, were calculated for disability, pain and quality of life outcome at 3 months follow-up. The medium and high-risk group in the SBST were collapsed in the analyses due to few patients in the high-risk group. The prognostic ability was assessed using the explained variance (R2) of the outcomes from univariable and multivariable linear regression and beta values with 95% CIs were used to assess the prognostic value of individual items. RESULTS: The SBST classified 107 (67.7%) patients as low risk and 51 (32.3%) patients as medium/high risk. SBST provided prognostic ability for disability (R2=0.35), pain (R2=0.25) and quality of life (R2=0.28). Expectation for return to work predicted outcome in univariable analyses but provided limited additional prognostic ability when added to the SBST. Present work ability provided additional prognostic ability for disability (ß=-2.5; 95% CI=-3.6 to -1.4), pain (ß=-0.2; 95% CI=-0.5 to -0.002) and quality of life (ß=0.02; 95% CI=0.001 to 0.04) in the multivariable analyses. The explained variance (R2) when work ability was added to the SBST was 0.60, 0.49 and 0.47 for disability, pain and quality of life, respectively. CONCLUSIONS: Adding one work ability item to the SBST gives additional prognostic information across core outcomes. Clinical trial number: NCT03626389.

Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials.

BACKGROUND: Low back pain is one of the leading causes of disability worldwide. Exercise therapy is widely recommended to treat persistent non-specific low back pain. While evidence suggests exercise is, on average, moderately effective, there remains uncertainty about which individuals might benefit the most from exercise. METHODS: In parallel with a Cochrane review update, we requested individual participant data (IPD) from high-quality randomised clinical trials of adults with our two primary outcomes of interest, pain and functional limitations, and calculated global recovery. We compiled a master data set including baseline participant characteristics, exercise and comparison characteristics, and outcomes at short-term, moderate-term and long-term follow-up. We conducted descriptive analyses and one-stage IPD meta-analysis using multilevel mixed-effects regression of the overall treatment effect and prespecified potential treatment effect modifiers. RESULTS: We received IPD for 27 trials (3514 participants). For studies included in this analysis, compared with no treatment/usual care, exercise therapy on average reduced pain (mean effect/100 (95% CI) -10.7 (-14.1 to -7.4)), a result compatible with a clinically important 20% smallest worthwhile effect. Exercise therapy reduced functional limitations with a clinically important 23% improvement (mean effect/100 (95% CI) -10.2 (-13.2 to -7.3)) at short-term follow-up. Not having heavy physical demands at work and medication use for low back pain were potential treatment effect modifiers-these were associated with superior exercise outcomes relative to non-exercise comparisons. Lower body mass index was also associated with better outcomes in exercise compared with no treatment/usual care. This study was limited by inconsistent availability and measurement of participant characteristics. CONCLUSIONS: This study provides potentially useful information to help treat patients and design future studies of exercise interventions that are better matched to specific subgroups. PROTOCOL PUBLICATION: https://doi.org/10.1186/2046-4053-1-64.

Longitudinal associations of kinematics and fear-avoidance beliefs with disability, work ability and pain intensity in persons with low back pain.

BACKGROUND: Impaired lumbar movement has cross-sectionally been associated with low back pain (LBP); however, the consequence of impaired movement on disability and pain in persons with LBP is poorly understood. Furthermore, fear-avoidance beliefs (FAB) may influence spinal movement, but the relation between fear-avoidance and kinematics is unclear. OBJECTIVES: To investigate the longitudinal associations of kinematics and FAB with disability, work ability and pain in patients with LBP. Further, to explore associations between FAB and kinematics. DESIGN: Prospective observational study. METHOD: Kinematic measures were performed on 44 persons with LBP at baseline, three and nine months. Motion sensors identified range-of-motion and velocity during a spinal flexion/extension. FAB, disability, work ability and pain were reported at all time points using questionnaires. RESULTS: Increased range-of-motion was weakly associated with less disability (-0.14 points, 95% CI -0.22 to -0.06). Velocity was not associated with disability, work ability or pain. Higher FAB of physical activity were associated with more disability (1.50 points, 95% CI 0.51 to 2.49) and pain (0.37 points, 95% CI 0.11 to 0.62). Higher work-related FAB was associated with lower work ability (-0.37 points, 95% CI -0.68 to -0.05). Moreover, higher FAB showed weak associations with lower velocity in the initial movement phase (-3.3°/s, 95% CI -6.1 to -0.5). CONCLUSIONS: Of the kinematic measures, only range-of-motion was related to disability. Higher FAB was weakly associated with all self-reported outcomes and with lower velocity only at the initial flexion phase. However, the magnitude of these associations suggest marginal clinical importance.

Improvement in Work Ability, Psychological Distress and Pain Sites in Relation to Low Back Pain Prognosis: A Longitudinal Observational Study in Primary Care.

STUDY DESIGN: Prospective observational study pooled from two clinical cohorts. OBJECTIVE: To investigate the longitudinal relation between multisite pain, psychological distress, and work ability with disability, pain, and quality of life. SUMMARY OF BACKGROUND DATA: Knowledge of prognostic factors is essential for better management of patients with low back pain (LBP). All domains of the biopsychosocial model have shown prognostic value; however, clinical studies rarely incorporate all domains when studying treatment outcome for patients with LBP. METHODS: A total of 165 patients with nonspecific LBP seeking primary care physiotherapy were included. Mixed-effects models were used to estimate longitudinal relations between the exposure variables and concurrent measures of outcomes at baseline and 3 months. Logistic regression was used to estimate odds ratios for minimal important difference in outcome. RESULTS: Higher work ability was associated with less disability -2.6 (95% confidence interval [CI]: -3.3, -2.0), less pain: -0.4 (95% CI: -0.5, -0.3), and higher quality of life 0.03 (95% CI: 0.02, 0.04). Higher psychological distress and number of pain sites were associated with higher disability: 10.9 (95% CI: 7.7, 14.1) and 2.3 (95% CI: 1.4, 3.2) higher pain: 1.9 (95% CI: 1.3, 2.5) and 0.4 (95% CI: 0.2, 0.5), and lower quality of life: -0.1 (95% CI: -0.2, -0.1) and -0.02 (95% CI: -0.03, -0.01), respectively. Improvement in work ability showed consistent associations with successful outcome for disability (odds ratio [OR]: 4.8, 95% CI: 1.3, 18.1), pain (OR: 3.6, 95% CI: 1.1, 12.1), and quality of life (OR: 4.5, 95% CI: 1.4, 15.1) at 3 months. Reduced psychological distress was associated with improvement in pain only (OR 4.0, 95% CI: 1.3, 12.3). CONCLUSION: More pain sites, higher psychological distress, or lower work ability showed higher disability, more pain, and lower quality of life in patients with LBP. Only improvement in work ability was consistently related to successful outcomes. LEVEL OF EVIDENCE: 2.

Risk classification of patients referred to secondary care for low back pain.

BACKGROUND: Nonspecific low back pain is characterized by a wide range of possible triggering and conserving factors, and initial screening needs to scope widely with multilevel addressment of possible factors contributing to the pain experience. Screening tools for classification of patients have been developed to support clinicians. The primary aim of this study was to assess the criterion validity of STarT Back Screening Tool (STarT Back) against the more comprehensive Örebro Musculoskeletal Pain Questionnaire (ÖMPSQ), in a Norwegian sample of patients referred to secondary care for low back pain. Secondary aims were to assess risk classification of the patients, as indicated by both instruments, and to compare pain and work characteristics between patients in the different STarT Back risk categories. METHODS: An observational, cross-sectional survey among patients with low back pain referred to outpatient secondary care assessment at Trondheim University Hospital, Norway. Cohen's Kappa coefficient, Pearson's r and a Bland-Altman plot were used to assess criterion validity of STarT Back against ÖMPSQ. Furthermore, linear regression was used to estimate mean differences with 95% CI in pain and work related variables between the risk groups defined by the STarT Back tool. RESULTS: A total of 182 persons participated in the study. The Pearsons correlation coefficient for correspondence between scores on ÖMPSQ and STarT Back was 0.76. The Kappa value for classification agreement between the instruments was 0.35. Risk group classification according to STarT Back allocated 34.1% of the patients in the low risk group, 42.3% in the medium risk, and 23.6% in the high risk group. According to ÖMPSQ, 24.7% of the participants were allocated in the low risk group, 28.6% in the medium risk, and 46.7% in the high risk group. Patients classified with high risk according to Start Back showed a higher score on pain and work related characteristics as measured by ÖMPSQ. CONCLUSION: The correlation between score on the screening tools was good, while the classification agreement between the screening instruments was low. Screening for work factors may be important in patients referred to multidisciplinary management in secondary care.

The influence of multisite pain and psychological comorbidity on prognosis of chronic low back pain: longitudinal data from the Norwegian HUNT Study.

OBJECTIVES: This study aimed to investigate the prospective influence of multisite pain, depression, anxiety, self-rated health and pain-related disability on recovery from chronic low back pain (LBP). SETTING: The data is derived from the second (1995-1997) and third (2006-2008) wave of the Nord-Trøndelag Health Study (HUNT) in Norway. PARTICIPANTS: The study population comprises 4484 women and 3039 men in the Norwegian HUNT Study who reported chronic LBP at baseline in 1995-1997. PRIMARY OUTCOME MEASURES: The primary outcome was recovery from chronic LBP at the 11-year follow-up. Persons not reporting pain and/or stiffness for at least three consecutive months during the last year were defined as recovered. A Poisson regression model was used to estimate adjusted risk ratios (RRs) with 95% CIs. RESULTS: At follow-up, 1822 (40.6%) women and 1578 (51.9%) men reported recovery from chronic LBP. The probability of recovery was inversely associated with number of pain sites (P-trend<0.001). Compared with reporting 2-3 pain sites, persons with only LBP had a slightly higher probability of recovery (RR 1.10, 95% CI 0.98 to 1.22 in women and RR 1.10, 95% CI 1.01 to 1.21 in men), whereas people reporting 6-9 pain sites had substantially lower probability of recovery (RR 0.58, 95% CI 0.52 to 0.63 in women and RR 0.70, 95% CI 0.63 to 0.79 in men). Poor/not so good self-rated general health, symptoms of anxiety and depression, and pain-related disability in work and leisure were all associated with reduced probability of recovery, but there was no statistical interaction between multisite pain and these comorbidities. CONCLUSIONS: Increasing number of pain sites was inversely associated with recovery from chronic LBP. In addition, factors such as poor self-rated health, psychological symptoms and pain-related disability may further reduce the probability of recovery from chronic LBP.

Can Sonography Be Used to Estimate Deep Abdominal Muscle Activation in Different Static Arm Positions While Standing?

OBJECTIVES: The aim of this study was to investigate whether sonography is a reliable tool for measuring deep abdominal muscle activation in different static arm positions while standing. METHODS: Sonographic recordings were made of the transversus abdominis and obliquus internus abdominis in 4 different static arm positions that varied with regard to the postural demand and loading direction posed on the trunk. Ten nonconsecutive repetitions of each arm position were performed, and thickness measurements were made at 2 locations within each muscle. Reliability was analyzed by the generalizability theory; comparisons regarding thickness measurements were made by repeated-measures analyses of variance; and fascial sliding was analyzed by a 1-sample t test. RESULTS: Averaged over all repetitions, arm positions, and the 2 measurement locations, the thickness measurements were highly reliable for both the obliquus internus abdominis and transversus abdominis. The transversus abdominis was thicker with shoulders flexed than with shoulders extended or arms above the head (P < .021) and with arms alongside the body compared with shoulders extended (P < .005). There was no thickness difference between arm positions for the obliquus internus abdominis (P = .059). CONCLUSIONS: The results indicate that sonographic recordings of the obliquus internus abdominis and transversus abdominis in different static arm positions while standing provide reliable measurements of muscle thickness. However, in light of previously reported electromyographic data, the results raise some concerns regarding the validity of using thickness measurements as proxies for muscle activation in positions that may induce passive muscle deformation.

Exercises for Women with Persistent Pelvic and Low Back Pain after Pregnancy.

BACKGROUND: Specific stabilizing exercises activating deep local muscles in coordination with global muscles are recommended in the treatment of pregnancy-related lumbopelvic pain. Some studies have suggested that recruitment of the deepest abdominal muscle, transversus abdominis, is crucial in the development and improvement of lumbopelvic pain. OBJECTIVE: This exploratory study aimed to describe the development of pain, disability and transversus abdominis recruitment before, during and after an individually designed intervention including an exercise program for women with persisting lumbopelvic pain after delivery. DESIGN: A multiple-baseline, single-subject experimental design was applied. METHODS: Sixteen women with lumbopelvic pain after delivery were included and received tailored exercise therapy, including ultrasound-guided activation of deep muscles, strengthening and stretching exercises and advice. Pain, disability and ultrasound-recorded activation of transversus abdominis was registered weekly. Treatment and testing was performed in a primary care setting in Trondheim, Norway. RESULTS: All sixteen included women reported reduced pain and decreased disability over the intervention period. The magnitude of transversus abdominis activation varied substantially between individuals and tests. While there was a statistically significant correlation between change in pain and change in disability, no correlation was observed between change in transversus abdominis activation and change in symptoms. LIMITATIONS: This is an exploratory study and results cannot be generalized without replication in controlled studies. CONCLUSIONS: Pain and disability due to persistent low back and pelvic pain after delivery were reduced after specific, individual adapted exercise including deep and superficial lumbopelvic muscles. Changes in pain and disability were not associated with changes in transversus abdominis activation.

Are fear avoidance beliefs associated with abdominal muscle activation outcome for patients with low back pain?

BACKGROUND AND PURPOSE: Activation of transversus abdominis and fear avoidance beliefs have both been related to low back pain (LBP). This exploratory study aims to investigate associations between fear avoidance beliefs at baseline and deep abdominal muscle activation after an 8-week period of supervised exercises for chronic LBP. METHODS: A cohort of patients with chronic non-specific LBP (N = 108) enrolled in a clinical trial was studied longitudinally. Fear avoidance beliefs for physical activity and work were measured before intervention. Activation in transversus abdominis and obliquus internus abdominis during abdominal drawing-in manoeuvre and rapid arm flexion was measured by ultrasound before and after intervention. Associations between baseline fear avoidance beliefs and deep abdominal muscle activation after exercises were analysed with multiple linear regression methods. RESULTS: High fear avoidance beliefs for physical activity (≥16 on the subscale) were negatively associated with transversus abdominis slide after the intervention period, ß = -4.92 (-8.40 to -1.45). There were no associations between fear avoidance beliefs for physical activity and abdominal muscle onset, transversus abdominis or obliquus internus contraction ratio. Fear avoidance beliefs for work were not associated with any of the muscle activation parameters. CONCLUSION: This study suggests that there is some negative association between fear avoidance beliefs for physical activity before intervention and transversus abdominis recruitment measured by lateral slide after intervention. No other significant associations between fear avoidance beliefs and abdominal muscle activation were found. We cannot exclude random findings, meaning that the results should be considered hypothesis generating for further investigations.

Is activation of transversus abdominis and obliquus internus abdominis associated with long-term changes in chronic low back pain? A prospective study with 1-year follow-up.

OBJECTIVE: To investigate associations between deep abdominal muscle activation and long-term pain outcome in chronic non-specific low back pain (LBP). METHODS: Recruitment of transversus abdominis and obliquus internus abdominis during the abdominal drawing-in manoeuvre was recorded by B-mode ultrasound and anticipatory onset of deep abdominal muscle activity with M-mode ultrasound. Recordings were done before and after 8 weeks with guided exercises for 109 patients with chronic non-specific LBP. Pain was assessed with a numeric rating scale (0-10) before and 1 year after intervention. Associations between muscle activation and long-term pain were examined by multiple linear and logistic regression methods. RESULTS: Participants with a combination of low baseline lateral slide in transversus abdominis and increased slide after intervention had better odds for long-term clinically important pain reduction (≥2 points on the numeric rating scale) compared with participants with small baseline slide and no improvement in slide (OR 14.70, 95% CI 2.41 to 89.56). There were no associations between contraction thickness ratios in transversus abdominis or obliquus internus abdominis and pain at 1-year follow-up. Transversus abdominis lateral slide before intervention was marginally associated with a lower OR for clinically important improvement in pain at 1-year follow-up (OR 0.76, 95% CI 0.62 to 0.93). Delayed onset of the abdominal muscles after the intervention period was weakly associated with higher long-term pain. CONCLUSION: Improved transversus abdominis lateral slide among participants with low baseline slide was associated with clinically important long-term pain reduction. High baseline slide and delayed onset of abdominal muscles after the intervention period were weakly associated with higher pain at 1-year follow-up. Clinical Trial Registration number The study was preregistered in ClinicalTrials.gov with identifier NCT00201513.

Effect of core stability exercises on feed-forward activation of deep abdominal muscles in chronic low back pain: a randomized controlled trial.

STUDY DESIGN: A randomized controlled trial. OBJECTIVE: To investigate feed-forward activation or timing of abdominal muscle activation in response to rapid shoulder flexion after 8 weeks with core stability exercises, sling exercises, or general exercises in chronic nonspecific low back pain (LBP) patients. SUMMARY OF BACKGROUND DATA: Delayed onset in abdominal muscles has been associated with LBP. Low load exercises to volitionally activate the transversus abdominis were introduced to restore trunk muscle activation deficits. More forceful co-contraction exercises have been advocated by others. This study explored whether abdominal muscle onset changed after low-load core stability exercises, high-load sling exercises, or general exercises. METHODS: Subjects (N = 109) with chronic nonspecific LBP of at least 3 months' duration were randomly assigned to 8 weekly treatments with low-load core stability exercises, high-load stabilizing exercises in slings, or general exercises in groups. Primary outcome was onset recorded bilaterally by m-mode ultrasound imaging in the deep abdominal muscles in response to rapid shoulder flexion. RESULTS: No or small changes were found in onset after treatment. Baseline adjusted between group differences showed a 15 ms (95% confidence interval [CI], 1-28; P = 0.03) and a 19 ms (95% CI, 5-33; P < 0.01) improvement with sling relative to core stability and general exercises, respectively, but on 1 side only. There was no association between changes in pain and onset over the intervention period (R ≤ 0.02). CONCLUSION: Abdominal muscle onset was largely unaffected by 8 weeks of exercises in chronic LBP patients. There was no association between change in onset and LBP. Large individual variations in activation pattern of the deep abdominal muscles may justify exploration of differential effects in subgroups of LBP.

Motor control exercises, sling exercises, and general exercises for patients with chronic low back pain: a randomized controlled trial with 1-year follow-up.

BACKGROUND: Exercise benefits patients with chronic nonspecific low back pain; however, the most effective type of exercise remains unknown. OBJECTIVE: This study compared outcomes after motor control exercises, sling exercises, and general exercises for low back pain. DESIGN: This was a randomized controlled trial with a 1-year follow-up. SETTING: The study was conducted in a primary care setting in Norway. PATIENTS: The participants were patients with chronic nonspecific low back pain (n=109). INTERVENTIONS: The interventions in this study were low-load motor control exercises, high-load sling exercises, or general exercises, all delivered by experienced physical therapists, once a week for 8 weeks. MEASUREMENTS: The primary outcome measure was pain reported on the Numeric Pain Rating Scale after treatment and at a 1-year follow-up. Secondary outcome measures were self-reported activity limitation (assessed with the Oswestry Disability Index), clinically examined function (assessed with the Fingertip-to-Floor Test), and fear-avoidance beliefs after intervention. RESULTS: The postintervention assessment showed no significant differences among groups with respect to pain (overall group difference) or any of the outcome measures. Mean (95% confidence interval) group differences for pain reduction after treatment and after 1 year were 0.3 (-0.7 to 1.3) and 0.4 (-0.7 to 1.4) for motor control exercises versus sling exercises, 0.7 (-0.6 to 2.0) and 0.3 (-0.8 to 1.4) for sling exercises versus general exercises, and 1.0 (-0.1 to 2.0) and 0.7 (-0.3 to 1.7) for motor control exercises versus general exercises. LIMITATIONS: The nature of the interventions made blinding impossible. CONCLUSIONS: This study gave no evidence that 8 treatments with individually instructed motor control exercises or sling exercises were superior to general exercises for chronic low back pain.