Phys Ther 2012 Macedo 363 77

Effect of Motor Control Exercises Versus Graded
Activity in Patients With Chronic Nonspecific Low

Back Pain: A Randomized Controlled Trial
Luciana Gazzi Macedo, Jane Latimer, Christopher G.
Maher, Paul W. Hodges, James H. McAuley, Michael K.
Nicholas, Lois Tonkin, Chris J. Stanton, Tasha R.
Stanton and Ryan Stafford
PHYS THER. 2012; 92:363-377.
Originally published online December 1, 2011
doi: 10.2522/ptj.20110290
The online version of this article, along with updated information and services, can be
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Research Report
Effect of Motor Control Exercises
Versus Graded Activity in Patients
With Chronic Nonspecific Low Back
Pain: A Randomized Controlled Trial
Luciana Gazzi Macedo, Jane Latimer, Christopher G. Maher, Paul W. Hodges,
James H. McAuley, Michael K. Nicholas, Lois Tonkin, Chris J. Stanton,
Tasha R. Stanton, Ryan Stafford
Background. Motor control exercises to improve control and coordination of

trunk muscles and graded activity under the principles of cognitive-behavioral therapy are 2 commonly used exercise therapies, yet there is little evidence to support
the use of one intervention over the other.
Objective. The objective of this study was to compare the effectiveness of motor
control exercises and graded activity for patients with chronic nonspecific low back
pain.
Design. This study was a prospectively registered randomized controlled trial with
outcome assessment and statistical analyses conducted blind to group.
Setting. The study was conducted in primary care settings.

Patients. The participants were 172 patients with chronic (12 weeks) nonspecific low back pain.
Interventions. Patients were randomly assigned to receive either motor control

exercises or graded activity. There was no attempt to subclassify patients to match
them to a treatment. Patients in both groups received 14 sessions of individualized,
supervised exercise therapy.
Measurements. Primary outcomes were average pain over the previous week
(numeric rating scale) and function (Patient-Specific Functional Scale); secondary
outcomes were disability (24-item Roland-Morris Disability Questionnaire), global
impression of change (Global Perceived Effect Scale), and quality of life (36-Item
Short-Form Health Survey questionnaire [SF-36]). Outcome measures were collected
at baseline and at 2, 6, and 12 months after intervention.
Results. A linear mixed models analysis showed that there were no significant
differences between treatment groups at any of the time points for any of the
outcomes studied. For example, the effect for pain at 2 months was 0.0 (0.7 to 0.8).
L.G. Macedo, PT, PhD, Common

Spinal Disorders Research Group,
Department of Physical Therapy,
University of Alberta, 2-50 Corbett Hall, Edmonton, Alberta,
Canada T6G 2G4. Address all correspondence to Dr Macedo at:
lmacedo@ualberta.ca.
J. Latimer, PT, PhD, Musculoskeletal Division, The George Institute
for Global Health, Sydney, New
South Wales, Australia.
C.G. Maher, PT, PhD, Musculoskeletal Division, The George Institute for Global Health.
P.W. Hodges, PT, PhD, NHMRC
Centre of Clinical Research
Excellence in Spinal Pain, Injury
and Health, The University of
Queensland, Brisbane, Queensland, Australia.
J.H. McAuley, PhD, Neuroscience
Research Australia, Sydney, New
South Wales, Australia.
M.K. Nicholas, PhD, Pain Management Research Institute, The
University of Sydney at Royal
North Shore Hospital, Sydney,
New South Wales, Australia.
L. Tonkin, BScPT, Pain Management Research Institute, The University of Sydney at Royal North
Shore Hospital.
Author information continues on
next page.
Limitations. Clinicians could not be blinded to the interventions.

Conclusion. The results of this study suggest that motor control exercises and
graded activity have similar effects for patients with chronic nonspecific low back
pain.
March 2012
Volume 92 Number 3
Post a Rapid Response to

this article at:
ptjournal.apta.org
Physical Therapy f
363
Motor Control Versus Graded Activity for Low Back Pain

C.J. Stanton, BSc, Musculoskeletal Division,
The George Institute for Global Health.
T.R. Stanton, PT, PhD, The Sansom Institute
for Health Research, The University of South
Australia, Adelaide, South Australia, Australia, and Neuroscience Research Australia.
R. Stafford, NHMRC Centre of Clinical
Research Excellence in Spinal Pain, Injury
and Health, The University of Queensland.
[Macedo LG, Latimer J, Maher CG, et al.
Effect of motor control exercises versus
graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial. Phys Ther. 2012;92:363377.]
2012 American Physical Therapy Association
Published Ahead of Print: December 1, 2011
Accepted: October 22, 2011
Submitted: September 6, 2011
upervised exercise therapies

are among the most commonly
advocated treatments for chronic
nonspecific low back pain.1,2 However, despite the growing number of
studies evaluating the effectiveness of
exercise interventions, there is still
considerable debate with regard to
the most appropriate form of exercise.3 Systematic reviews evaluating
the effectiveness of exercise therapies commonly conclude that, to
date, there is no evidence to support
the superiority of one form of exercise over another.35
Among the wide variety of supervised exercise therapies available,
motor control exercises and graded
activity under the principles of
cognitive-behavioral therapy are the
most popular and promising forms
of exercise for patients with chronic
low back pain.1,3,6 The primary reason for their popularity is that, unlike
some other forms of exercise, each
has a specific rationale for its mechanisms of action in addition to evidence of their efficacy from randomized controlled trials and systematic
reviews.4,5 For these reasons, many
health professionals believe that
these 2 forms of exercise may have
superior effects compared with
other forms of exercise therapy.
Motor control exercises were developed based on the results of laboratory studies demonstrating that individuals with low back pain have
impaired control of the deep (eg,
transversus abdominis and multifidus) and superficial trunk muscles
responsible for maintaining the stability of the spine.710 Motor control
exercises utilize principles of motor
learning to retrain control of the trunk
muscles, posture, and movement pattern,11 ultimately leading to a reduction in the levels of pain and disability.
Graded activity exercises were
developed based on studies suggesting that cognitive-behavioral aspects,
364
Physical Therapy
such as the patients mood and cognition, are important factors associated with delayed recovery from
back pain and with increased levels
of disability in patients with chronic
pain.1217 This cognitive-behavioral
model assumes that disability is
determined not only by the underlying pathology, but also by social,
cognitive, emotional, and behavioral
factors.18 Therefore, graded activity
exercises aim to reduce pain and disability by addressing pain-related
fear, kinesiophobia, and unhelpful
beliefs and behaviors about back
pain19 while correcting physical
impairments such as reduced endurance, muscle strength, or balance.20
Systematic reviews have suggested
that motor control exercise and
graded activity are effective in reducing pain and disability in patients
with nonspecific low back pain
compared with a minimal intervention approach.4,5 However, only one
study has directly compared the
effectiveness of motor control exercises and graded activity.21 This
randomized controlled trial showed
no significant differences between
groups in relation to pain or disability
at 6-, 12-, and 18-month follow-ups;
however, the study had more than
22% loss to follow-up in both groups,
which decreases confidence in the
results. In addition, the trial protocol
was not registered or published prior
to beginning data collection, and
both interventions were administered in a group format that may not
be considered an optimal way to
implement these interventions.22
Motor control exercises and graded
activity are used in clinical practice,
although limited information is available to guide clinical decision making. In view of the limitations of the
only trial that compared the effectiveness of these 2 interventions, we
believed it was imperative to conduct a high-quality randomized controlled trial where the 2 exercise pro-
Volume 92 Number 3
March 2012

grams could be directly compared in
patients with chronic nonspecific
low back pain.
Method
Design Overview
This study was a randomized controlled trial where patients received
an intervention for approximately
8 weeks, with follow-ups at 2, 6,
and 12 months after intervention.
This trial was prospectively registered
(ACTRN12607000432415), and the
protocol has previously been published.23 All patients signed an
informed consent form prior to their
inclusion into the study.
Setting and Patients
Participants were recruited to the
trial by general practitioners in Sydney and Brisbane or drawn from
the waiting list of an outpatient physical therapy department from a public hospital in Sydney. Five patients
were recruited by one of the investigators, who identified eligible patients
who responded to an advertisement
for participation in another set of
studies of back pain in Brisbane.
Patients were eligible for inclusion if
they met all of the following inclusion criteria:
chronic nonspecific low back pain
(3 months duration) with or
without leg pain
currently seeking care for low back
pain
between 18 and 80 years of age
English speaker (to allow response
to the questionnaires and communication with the physical
therapist)
clinical assessment indicated that
the patient was suitable for active
exercises
expected to continue residing in
the Sydney or Brisbane region for
the study duration
had a score of moderate or greater
on question 7 (How much bodily
pain have you had during the past
March 2012
week?) or question 8 (During the

past week, how much did pain
interfere with your normal work,
including both work outside the
home and housework?) of the
36-Item Short-Form Health Survey
questionnaire (SF-36).24
Exclusion criteria were:

known or suspected serious pathology such as nerve root compromise
(at least 2 of the following signs:
weakness, reflex changes, or sensation loss, associated with the same
spinal nerve)
previous spinal surgery or scheduled for surgery during trial period
comorbid health conditions that
would prevent active participation
in exercise programs.
We used a red flag checklist to

screen for serious pathology and the
Physical Activity Readiness Questionnaire from the American College
of Sports Medicine guidelines25 to
screen for comorbid health condi-
tions that would prevent safe participation in exercise.

Randomization
and Interventions
The randomization sequence was
computer generated by an investigator not involved in recruitment
or treatment allocation. Two sets
of randomization schedules were
created: one for the patients to be
recruited in Sydney (100 envelopes)
and one for patients to be recruited
in Brisbane (72 envelopes). Both
sequences were blocked (block
sizes of 4, 6, and 8, in random
order). Allocation was concealed
in sequentially numbered, sealed,
opaque envelopes by an investigator
not involved in the study. Eligible
patients were allocated to the treatment groups by the physical therapist who drew the next available
envelope at the first treatment session. Because of time constraints due
to funding and because we were able
to recruit more participants in Sydney than in Brisbane, the last 33 ran-
The Bottom Line

What do we already know about this topic?
Motor control exercises to improve control and coordination of trunk
muscles and graded activity under the principles of cognitive-behavioral
therapy are 2 commonly used exercise therapies for chronic nonspecific
low back pain, yet there is little evidence to support the use of one
intervention over the other.
What new information does this study offer?

The results of this randomized controlled trial suggest that motor control
exercises and graded activity have similar effects on the general population of patients with chronic nonspecific low back pain.
If youre a patient or a caregiver, what might these

findings mean for you?
Well-designed and well-implemented exercise programs are an effective
treatment for chronic low back pain, but the type of exercise does not
seem to be particularly important. Your physical therapist might prescribe
either exercise program for your low back pain.
Volume 92 Number 3
Physical Therapy f
365

domization envelopes initially allocated to Brisbane were transferred to
the Sydney site. No attempt was
made to evaluate the effect of site on
trial outcomes.
Participants in each group were to
receive 14 individually supervised
sessions of approximately 1 hour.
The treatment consisted of 12 initial
treatment sessions over an 8-week
period and 2 booster sessions at 4
and 10 months following randomization. The initial 12 sessions were
conducted twice a week for the first
4 weeks and once a week for the
following 4 weeks. The treatment
sessions were designed to become
less frequent and promote independence. In order to facilitate adherence to treatment sessions and to be
consistent with clinical practice, if
patients could not complete the initial 12 treatment sessions within the
first 8 weeks, they received an extension of another 4 weeks to complete
the 12 treatment sessions. Patients
included in both exercise programs
were advised to do home exercises
for at least half an hour per week in
the first month and 1 hour per week
in the second month. The type of
home exercises, intensity, and number of sessions per day were at the
discretion of the physical therapist.
Trial interventions were provided
by 10 physical therapists with at
least 2 years of clinical experience
who received training in motor control exercises and graded activity.
Therefore, all therapists provided
both interventions. The training
included a 2-day workshop for the
motor control exercises and a series
of evening interactive seminars for
graded activity, both administered
by recognized experts in the field.
The same experts performed audits
of trial treatment of most of the
treating physical therapists to evaluate and encourage compliance with
the treatment protocols. Although
we do not have the specific data nec366
Physical Therapy
essary to evaluate the physical therapists compliance with the treatment protocols, our audits revealed
that most physical therapists followed the treatment protocols and
there was no evidence of crosscontamination. The physical therapists worked at private clinical practices or at the university clinic.
Motor Control Exercises
The motor control exercise program
was based on the treatment program reported by Hodges et al11 and
similar to the protocol previously
used by Ferreira et al26 and Costa
et al.27 A primary goal of the exercise
was to enable the patient to regain
control and coordination of the
spine and pelvis using principles of
motor learning such as segmentation
and simplification. The intervention
was based on assessment of the individual participants motor control
impairments and treatment goals (set
collaboratively with the therapist).
The first stage of the treatment
involved assessment of the postures,
movement patterns, and muscle activation associated with symptoms
and implementation of a retraining
program designed to improve activity of muscles assessed to have poor
control (commonly, but not limited
to, the deeper muscles such as transversus abdominis, multifidus, pelvic
floor, and diaphragm) and reducing
activity of any muscle identified to
be overactive, commonly the large,
more superficial trunk muscles such
as the obliquus externus abdominis.11 Participants were taught how
to contract trunk muscles in a specific manner26,27 and progress until
they were able to maintain isolated
contractions of the target muscles
for 10 repetitions of 10 seconds each
while maintaining normal respiration.28 Feedback such as palpation
and real-time ultrasound images
were available to enhance learning
of the tasks.29 During this stage, additional exercises for breathing con-
trol, posture of the spine, and lowerlimb and trunk movement were
performed.
The second stage of the treatment
involved the progression of the exercises toward more functional activities,27 first using static and then
dynamic tasks. Throughout this process, the recruitment of the trunk
muscles, posture, movement pattern, and breathing were assessed
and corrected.11 In contrast to the
graded activity program, motor control exercise was guided by pain, and
exercises were mostly pain-free.
Graded Activity
The graded activity program was
based on the treatment program
originally reported by Lindstrom et
al30 and similar to the protocol previously used by Pengel et al31 and
Smeets et al.32 A primary goal of the
program was to increase activity tolerance by performing individualized and submaximal exercises,31
in addition to ignoring illness behaviors and reinforcing wellness behaviors. The program was based on
activities that each participant identified as problematic and that he
or she could not perform or had
difficulty performing because of
back pain. The activities in the program were progressed in a timecontingent manner (rather than a traditional pain-contingent manner)
from the baseline-assessed ability to
a target goal set jointly by participant and therapist.30,33,34 Participants received daily quotas and
were instructed to only perform the
agreed amount, not less or more,
even when they felt they were capable of doing more.32
Cognitive-behavioral principles were
used to help the participants overcome the natural anxiety associated with pain and activities.33,35
The physical therapists used positive reinforcement, explained pain
mechanisms, and addressed negative
Volume 92 Number 3
March 2012

behaviors and pain-related anxiety.33
A plan for managing relapses was
developed by the therapists and participants. Table 1 describes specific
differences between motor control
exercises and graded activity.
Table 1.
Differences Between Motor Control Exercise and Graded Activitya
Principles of the Interventions
Graded
Activity
Motor
Control
Exercise
Goal setting
Pain contingent
Outcome Measures
and Follow-up
All self-reported measures were collected by an investigator blinded
to treatment allocation. Measures
of outcome were obtained at baseline, immediately after treatment
(2 months), and at 6 months and
12 months after randomization.
Demographic characteristics such as
age, sex, weight, height, level of education, and employment status were
collected at baseline. We also collected information on psychological
profile, physical activity, and lumbar
spine instability using self-report
questionnaires at baseline. These
questionnaires included the Coping
rebro
Strategy Questionnaire,36 the O
Low Back Pain Screening Questionnaire,37 the 20-item Pain Anxiety
Symptom Scale (PASS-20),38 the Pain
Self-Efficacy Questionnaire,39 the
International Physical Activity Questionnaire (IPAQ),40 and the Lumbar
Spine Instability Questionnaire.41
Primary outcomes were average
pain intensity over the last week
(0 10 numeric rating scale [NRS])42
and function (0 10 Patient-Specific
Functional Scale [PSFS]) at the 2and 6-month follow-ups (the
12-month scores for these outcomes
were considered secondary outcomes).43 Secondary outcomes were
global impression of change (5
to 5 Global Perceived Effect Scale),43
disability (0 24 Roland-Morris Disability Questionnaire),44 and quality
of life (SF-36, version 1.0)24 reported
as physical component score (0
100) and mental component score
(0 100) when standardized using
the SF-36 Australian Population
Norms values for mean and standard
deviation45 measured at 2, 6, and 12
March 2012
Time contingent
Quotas/pacing
Reinforce wellness behavior and ignore illness

behavior
Education regarding pain system and reassurance
Education regarding ergonomic factors and body

awareness
Generalized (whole body) exercises with

consideration of specific muscle activity
Generalized (whole body) exercises without

consideration of specific muscle activity
Specific (localized) exercises
Focus on correct activation of muscles
Correction of posture
Strength training
Cardiovascular/fitness training
Coordination training
Correction of motor patterns
Muscle stretching
Breathing pattern
Consideration of continence
Correction of provocative movement patterns
Relaxation techniques
Progression to functional activities
Home exercises
Use feedback (eg, ultrasound, electromyography,

biofeedback) to enhance learning of
movement pattern or muscle activation
Check mark indicates principle applies to the intervention.
months. Because of a printing error,

there were only 5, not 6, response
options for question 9 of the SF-36
(ie, the option some of the time
was inadvertently omitted). However, the summary scores were still
calculated as per the SF-36 manual.
In addition, we measured recovery,
defined as a pain-free period that
lasted for at least 1 month.46 Information about side effects was collected using an open-ended question
(Have you experienced any side

effects during your 8-week treatment?). Participants rated the credibility of treatment (0 24 treatment
credibility scale)47 after the first
treatment session to allow an evaluation of whether patients expectations and beliefs were different
between treatment groups. At the
end of the treatment, participants
also rated how helpful, understanding, and friendly they found the therapists on a 7-point scale.31 Adher-
Volume 92 Number 3
Physical Therapy f
367

ence to home exercises was assessed
using a single question: How often
have you done your home program
of exercises (all the time, most of the
time, some of the time, a little of the
time, or none of the time)?
We also asked participants about
their pain every month over the 12
months of the study to evaluate the
fluctuating nature of chronic pain.
Participants were asked about their
pain at baseline and once a month
during the 1-year follow-up period.
The data were collected using an
automated SMS system. All messages
consisted of the following text:
Please rate on a 0 to 10 scale (0no
pain, 10worst pain): (a) average
pain over the last 24 hours and
(b) average pain over the previous
week. The automated system was
scheduled to send an SMS message at
10 a.m. every first, second, third, or
fourth Monday of the month according to the week that the participant
entered the study. If patients did not
reply to the first message, another
message was sent on the next day at
the same time. The same procedure
was performed for the following
day. Therefore, each participant had
3 chances to respond to the messages. The automated system also
sent an e-mail to the project coordinator with the names of the participants who had not responded to
each of the rounds of questions. If
the participants did not respond to
the third message, they were contacted via telephone to respond to
the questions.
Data Analysis
The sample size of 172 participants
was calculated a priori based on the
secondary goal of the study, not
reported in this article, which was
to identify predictors of response to
treatment. As larger sample sizes are
needed for evaluating interactions as
compared with main effects of studies, this study may have been overpowered for the main effects.23 Tak368
Physical Therapy
ing the standard deviation estimates

from previous studies,26,31 with an
alpha level of .05 and power of 0.80
and allowing for 10% loss to
follow-up and 10% treatment nonadherence, a sample size of 86 participants per group would allow us to
detect an interaction effect size of
1.0 standard deviation and a treatment main effect of 0.5 standard
deviation.
All data were double-entered, and
analyses were performed on a locked
data file. The statistical analyses were
performed using SPSS version 16.0
for Windows (SPSS Inc, Chicago, Illinois) and STATA version 9.0 (StataCorp LP, College Station, Texas) (linear mixed models) on an intentionto-treat basis. The investigator
performing the analyses was blinded
to treatment allocation, and all
analyses were double-checked by a
second blinded investigator. After
the study team had considered the
results of the statistical analyses
and agreed on their interpretation,
the results were unblinded. Independent t tests were used to determine whether there were significant
differences in treatment credibility
and treatment evaluation between
groups.
The mean effect of intervention on
pain, function, disability, global perceived effect, and quality of life
(divided into physical and mental
component scores) was calculated
using linear mixed models, which
incorporated terms for treatment,
time, and treatment time interactions. Because the linear mixed
model estimates values for missing
data, all randomized participants
were included in the analysis.48 The
effect of time was nonlinear, so time
was dummy coded and analyzed as a
categorical variable. The coefficients
of the treatment time interactions
provided the effects of graded activity over motor control exercise.
After inspecting the blinded recovery data, we realized that there were
limitations with our preplanned measure of recovery. The challenge was
that a number of participants who
met the definition of recovery (painfree for 1 month) had a recurrence in
the follow-up period. Because there
is a lack of consensus in the literature
regarding a standardized definition
of recovery,49 we developed 2 methods to define recovery. The first,
stricter measure was durable recovery, which required participants to
report no pain for at least 2 months
and no recurrence of pain over the
12 months of the study. The second,
more relaxed, method classified
participants as recovered if they
reported pain of 1 or less for any of
the SMS responses referring to pain
in the preceding week. Both classification methods were used to identify
participants who had recovered. Differences in recovery proportions
between treatment groups were analyzed using absolute risk reduction
and the Wilson method for calculating 95% confidence interval (CI) for
difference in proportions.
For the secondary outcome of pain
measured using SMS over the 12
months of the study, we estimated
the effect of treatment with a
group time interaction in a linear
mixed model. Time was entered in
the model as log of time and was
treated as a continuous variable. We
also plotted the SMS pain measures
over time and calculated the area
under the curve (AUC) for each participant (AUC values could range
from 0 to 120 units, representing
pain on the y axis and the 12 time
follow-ups on the x axis). We used
an independent t test to determine
whether the AUC was different
between treatment groups.
Role of the Funding Source
This trial received funding from Australias National Health and Medical
Research Council. The funding
Volume 92 Number 3
March 2012

source had no role in the planning or
conduct of the study.
Table 2.
Reasons for Ineligibility
Reason
Results
A total of 355 patients were referred
to the study and screened for inclusion between October 2007 and
November 2009. One hundred four
patients were not eligible, and 79
refused to participate. Reasons for
ineligibility are presented in Table 2.
The trial participant flowchart is presented in Figure 1. Nine participants
withdrew from the study: 2 from
the graded activity group (1 for not
improving and 1 unknown) and 7
from the motor control exercise
group (2 for lack of time, 1 for not
improving, 1 developed neurological signs, 1 was not happy with the
study protocol, and 2 unknown). In
terms of loss to follow-up, the main
reasons were the participants lack
of time and inability to contact the
participant. We did not identify significant differences at baseline for
the participants who withdrew or
were lost to follow-up. Baseline characteristics, including demographics
and baseline scores for both treatment groups, are reported in Table 3
and revealed that the randomization achieved groups that were well
balanced for important prognostic
factors.
Adherence to treatment in the initial 8-week period was excellent,
with both groups attending a mean
of 10.3 (SD3.6) of the planned 12
sessions. However, treatment adherence was lower for the 2 booster
treatment sessions and the home
program. Forty-three percent of the
participants in the graded activity
exercise attended the 4-month
booster treatment session and 31.4%
attended the 10-month booster treatment session. In the motor control
exercise group, attendance was 50%
and 25.6%, respectively. Participants
in the graded activity group reported
performing their home exercises: all
the time (23%), most of the time
March 2012
Low back pain of less than 3 months duration
30
Non-English speaker
13
Not expected to continue residing in the study area
12
Less than moderate pain or disability on question 7 or 8 of the SF-36a
11
Pain in a location other than the lower back
Nerve root compromise
Younger than 18 or older than 80 years of age
Suspected or confirmed serious pathology such as fracture or cancer
History of back surgery
Judged not fit to perform physical exercise
Not able to contact patient
Already undergoing treatment
SF-3636-Item Short-Form Health Survey questionnaire.
(44%), some of the time (19%), a

little of the time (6%), and none of
the time (2%). Participants in the
motor control exercise group
reported performing home exercises: all the time (15%), most of
the time (42%), some of the time
(26%), a little of the time (5%), and
none of the time (1%).
Treatment credibility measured after
the first treatment session and treatment evaluation at the end of the
treatment were not significantly different between treatment groups
(P.05 for all comparisons). The
mean score for treatment credibility was 19.8 (SD3.6) for the
graded activity group and 19.4
(SD4.1) for the motor control
exercise group (treatment credibility scored from 0 [not confident that treatment can help] to 24
[extremely confident that treatment
can help]). Mean scores for treatment evaluation (scale range: 0 [not
at all] to 6 [extremely]) in the graded
activity and motor control exercise
groups were 5.3 (SD1.0) and 5.2
(SD1.0), respectively, for therapist
helpfulness; 5.6 (SD0.7) and 5.4
understanding; 5.9 (SD0.4) and 5.7

friendliness; and 4.7 (SD1.2) and
4.7 (SD1.5), respectively, for treatment helpfulness.
Ten, 5, and 8 participants in the
graded activity group and 6,
17, and 9 participants in the motor
control exercise group reported
receiving cointerventions in addition to the trial treatment at the 2-,
6-, and 12-month follow-ups, respectively. Mild adverse effects were
reported for 17 participants in the
graded activity group and 19 participants in the motor control exercise group. Adverse effects were:
temporary exacerbation of pain
(n27), increased pain of preexisting musculoskeletal conditions
such as knee arthritis (n7), development of shin splints (n1), and
hip bursitis (n1). One participant
in the graded activity group reported
at the 6-month follow-up an exacerbation of symptoms that the medical
pain specialist attributed to one of
the home exercises that the participant was performing.
The estimates of treatment effects
from the linear mixed models
revealed that there were no statisti-
Volume 92 Number 3
Physical Therapy f
369
355 patients referred

to the study
79 refused to participate
104 ineligible
Randomization
n=172
Motor control exercise group=86

(Sydney=68, Brisbane=18)
All commenced allocated intervention
Graded activity group=86

(Sydney=65, Brisbane=21)
All commenced allocated intervention
Discontinued intervention (n=2; 1 not
improving, 1 unknown)
Allocation
Median=13 (5.25) treatments completed
Median=12 (4.25) treatments completed
Care providers performing the intervention

(n=8)
No. of patients treated by each care provider
(median=3.5, IQR=5.5)
Care providers
82 (95.3%) were followed up at 2 months

Lost to follow-up (n=4; 2 withdrew from
study, 2 unknown reason)
2-month
follow-up
Analyzed
n=86

study, 3 lack of time, 1 unknown)

6-month
follow-up

Care providers performing the intervention

(n=10)
No. of patients treated by each care provider
(median=9, IQR=5.5)

Discontinued intervention (n=8; 3 lack of

time, 1 not improving, 1 developed
neurological signs, 1 not happy with study
protocol, 2 unknown)
12-month
follow-up
Analyses

study, 3 not able to contact, 2 lack of time)

study, 4 not able to contact)
Analyzed
n=86
Figure 1.
Study flow diagram. IQRinterquartile ratio.
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Table 3.
Baseline Characteristics
Characteristic
Age (y), X (SD) [range]
Female, n (%)
Height (cm), X (SD)
Graded Activity Group

(n86)
Motor Control Exercise Group

(n86)
49.6 (16.3) [1880]
48.7 (13.7) [2075]
45 (52.3)
57 (66.3)
168.5 (10.1)
166.9 (9.2)
Weight (kg), X (SD)
80.8 (16.2)
75.7 (19.3)
Smoker, n (%)
14 (16.3)
16 (18.6)
57 (66.3)
52 (60.5)
Taking analgesics, n (%)

Low back pain duration (mo), X (SD)
Previous episode of low back pain, n (%)
100.7 (109.2)
74.0 (94.8)
57 (66.3)
54 (62.8)
23 (26.7)
25 (29.1)
Work status, n (%)

Working full-time
Working full-time, selected duties
Working part-time
1 (1.2)
4 (4.7)
16 (18.6)
18 (20.9)
Working part-time, selected duties
3 (3.5)
5 (5.8)
Not working
9 (10.5)
11 (12.8)
34 (39.5)
23 (26.7)
Not seeking employment

Education, n (%)
School certificate
15 (17.4)
14 (16.3)
High school certificate
24 (27.9)
16 (18.6)
Trade certificate, diploma, or advanced diploma
17 (19.8)
31 (36.1)
Bachelors degree or higher
20 (23.3)
19 (22.1)
8 (9.3)
4 (4.7)
Other (lower than school certificate)

Questionnaires, X (SD)
Coping Strategy Questionnairea
10.8 (7.6)
12.4 (7.5)
103.4 (26.9)
102.8 (20.4)
Total scorec
40.1 (21.8)
44.8 (21.0)
Cognitived
12.6 (7.1)
13.7 (6.3)
Escape/avoidanced
12.7 (6.3)
13.2 (6.0)
Feard
8.5 (6.6)
10.2 (6.6)
Physiological anxietyd
6.5 (5.6)
7.7 (5.8)
40.9 (13.5)
38.7 (12.3)
rebro Low Back Pain Screening Questionnaireb

O
Pain Anxiety Symptom Scale
Pain Self-Efficacy Questionnairee

International Physical Activity Questionnairef
Lumbar Spine Instability Questionnaireg
3,196 (6,634.9)
4,603.7 (8,012.4)
9.0 (3.1)
9.0 (2.7)
Pain intensity (NRS)h
6.1 (2.1)
6.1 (1.9)
Function (PSFS)i
3.6 (1.6)
3.7 (1.6)
Disability (RMDQ-24)j
11.2 (5.3)
11.4 (4.8)
Global impression of change (GPE)k
1.6 (2.6)
1.4 (2.3)
SF-36 physical component scorel
43.8 (10.3)
43.9 (10.8)
SF-36 mental component scorem
54.7 (11.5)
52.9 (10.5)
Outcome scores, X (SD)
Coping Strategy Questionnaire scored from 0 (good coping strategy) to 36 (worst coping strategy).
rebro Low Back Pain Screening Questionnaire scored from 11 (low risk of pain becoming persistent) to 192 (high risk of pain becoming persistent).
O
Pain Anxiety Symptom Scale total score, scored from 0 (low anxiety) to 100 (high anxiety).
d
Pain Anxiety Symptom Scale subscales of cognition, escape/avoidance, fear, and physiological anxiety, scored from 0 (low cognition, escape/avoidance,
fear, and physiological anxiety) to 25 (high cognition, escape/avoidance, fear, and physiological anxiety).
e
Pain Self-Efficacy Scale scored from 0 (high fear avoidance) to 100 (no fear avoidance).
f
International Physical Activity Questionnaire scored in metabolic equivalents-minutes/week.
g
Lumbar Spine Instability Questionnaire scored from 0 (no instability) to 15 (high instability).
h
NRSnumeric rating scale, scored from 0 (no pain) to 10 (worst pain).
i
PSFSPatient-Specific Functional Scale, scored from 0 (unable to perform activity) to 10 (able to perform activity at preinjury level).
j
RMDQ-2424-item Roland Morris Disability Questionnaire, scored from 0 (no disability) to 24 (high disability).
k
GPEGlobal Perceived Effect Scale, scored from 5 (vastly worse) to 5 (completely recovered).
l
Physical component score from the 36-Item Short-Form Health Survey questionnaire (SF-36) scored from 0 (low physical health) to 100 (high physical
health).
m
Mental component score from the SF-36 scored from 0 (low mental health) to 100 (high mental health).
b
c
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371

Table 4.
Outcomes for Each Treatment Group (Primary Outcomes in Bold Type)
Unadjusted X (SD)
Adjusted Treatment Effects
Graded
Activity Group
Motor Control
Exercise Group
X (95% CI)a
Baseline
6.1 (2.1)
6.1 (1.9)
n/ac
n/a
Outcome
Pain (NRS)
2 mo
4.1 (2.5)
4.1 (2.5)
0.0 (0.7 to 0.8)
.94
6 mo
4.1 (2.7)
4.1 (2.5)
0.0 (0.8 to 0.8)
.99
12 mo
3.7 (2.6)
3.7 (2.7)
0.1 (0.7 to 0.9)
.83
Baseline
3.6 (1.6)
3.7 (1.6)
n/a
n/a
2 mo
5.5 (2.4)
5.9 (2.1)
0.2 (0.5 to 0.9)
.53
Function (PSFS)d
6 mo
5.7 (2.4)
5.7 (2.3)
0.2 (0.9 to 0.5)
.53
12 mo
6.1 (2.3)
5.9 (2.2)
0.4 (1.1 to 0.3)
.25
11.2 (5.3)
11.4 (4.8)
2 mo
8.0 (6.5)
7.5 (6.4)
0.8 (2.2 to 0.7)
.30
6 mo
8.6 (6.8)
8.0 (7.1)
0.8 (2.3 to 0.6)
.26
12 mo
8.0 (6.9)
7.4 (6.7)
0.6 (2.0 to 0.9)
.45
1.6 (2.6)
1.4 (2.3)
2.0 (1.9)
2.0 (1.9)
Disability (RMDQ-24)
Baseline
n/a
n/a
Global impression of change (GPE)f

Baseline
2 mo
n/a
n/a
0.1 (1.0 to 0.7)
.74
6 mo
1.5 (2.5)
1.6 (2.4)
0.0 (0.9 to 0.8)
.91
12 mo
1.5 (2.5)
1.8 (2.5)
0.2 (0.6 to 1.0)
.62
Baseline
43.8 (10.3)
43.9 (10.8)
n/a
n/a
After treatment (2 mo)
51.6 (13.4)
51.6 (12.0)
0.2 (3.7 to 3.2)
.89
6 mo
51.2 (13.8)
52.6 (13.0)
1.1 (2.4 to 4.6)
.54
12 mo
53.3 (14.0)
53.8 (12.7)
0.3 (3.8 to 3.3)
.88
Baseline
54.7 (11.5)
52.9 (10.5)
n/a
n/a
2 mo
55.8 (13.0)
56.0 (10.9)
2.3 (0.7 to 5.3)
.14
6 mo
56.9 (11.8)
54.9 (10.4)
0.1 (3.0 to 3.1)
.97
12 mo
58.2 (10.8)
57.0 (10.1)
0.8 (2.3 to 3.9)
.62
SF-36 physical component score
SF-36 mental component scoreh
95% CI95% confidence interval.

NRSnumeric rating scale, scored from 0 (no pain) to 10 (worst pain).
n/anot applicable.
d
PSFSPatient-Specific Functional Scale, scored from 0 (unable to perform activity) to 10 (able to perform activity at preinjury level).
e
RMDQ-2424-item Roland-Morris Disability Questionnaire, scored from 0 (no disability) to 24 (high disability).
f
GPEGlobal Perceived Effect Scale, scored from 5 (vastly worse) to 5 (completely recovered).
g
Physical component score from the 36-Item Short-Form Health Survey questionnaire (SF-36) scored from 0 (low physical health) to 100 (high physical
health).
h
Mental component score from the SF-36 scored from 0 (low mental health) to 100 (high mental health).
b
c
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Figure 2.
Treatment outcomes at baseline and 2, 6, and 12 months after intervention. Values are unadjusted means and standard deviations.
NRSnumeric rating scale, PSFSPatient-Specific Functional Scale, RMDQ-2424-item Roland-Morris Disability Questionnaire,
GPEGlobal Perceived Effect Scale, MCSmental component score from the 36-Item Short-Form Health Survey questionnaire
(SF-36), PCSphysical component score from the SF-36.
March 2012
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Physical Therapy f
373

was 5% (95% CI5% to 15%) in
favor of graded activity over motor
control exercises. Thirty-eight participants (44%) in the graded activity
group and 35 participants (41%) in
the motor control exercise group
experienced recovery according to
the more lax criterion. Therefore,
the absolute risk reduction was 3%
(95% CI11% to 18%) in favor of
graded activity over motor control
exercises.
The analysis of the monthly SMS
pain measures using linear mixed
models showed that there was no
significant difference between the
2 treatment groups in pain over
the previous 24 hours (effect estimate0.9, 95% CI0.5 to 0.7,
P.78) and pain over the previous
week (effect estimate0.04, 95%
CI0.6 to 0.6, P.91). Figure 3
demonstrates the pain change over
time between groups. The mean
AUC for pain over the previous
24 hours was 42.4 (SD22.6) in
the graded activity group and
42.9 (SD24.6) in the motor control exercise group, with no significant
difference between treatment groups
(t.13, P.9). The mean AUC for
pain over the previous week was 43.0
(SD23.4) in the graded activity
group and 43.7 (SD24.0) in the
motor control exercise group, with no
significant difference between treatment groups (t.17, P.9).
Figure 3.
Monthly SMS pain outcomes in the 2 groups. Values are unadjusted means and
standard deviations. The upper panel illustrates pain over the previous 24 hours, and
the lower panel illustrates pain over the previous week.
cally significant, or clinically important, differences between treatment

groups for any of the outcomes at
any of the time points (Tab. 4 and
Fig. 2). Adjusted treatment effects
for the primary outcome of pain
(0 10 visual analog scale) were 0.0
(0.7 to 0.8) at 2 months and 0.0
(0.8 to 0.8) at 6 months and for
the primary outcome of function
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Physical Therapy
(0 10 PSFS) were 0.2 (0.5 to 0.9)

at 2 months and 0.2 (0.9 to 0.5)
at 6 months.
Twelve participants (14%) in the
graded activity group and 8 participants (9%) in the motor control
exercise group experienced durable recovery. For this measure of
recovery, the absolute risk reduction
Discussion
This comparative effectiveness trial
established that motor control exercises and graded activity have similar effects in reducing pain and
disability and increasing function,
global impression of change, and
quality of life in patients with
chronic nonspecific low back pain
at short-term, intermediate-term, and
long-term follow-up. The estimates
of treatment effect were precise and
exclude clinically important differences. The rates of recurrence in the
subsequent 12 months and adverse
Volume 92 Number 3
March 2012

effects with treatment also were similar in the 2 groups.
An important strength of this study
was that efforts were made to ensure
the optimal implementation of both
exercise interventions. The interventions included supervised, individualized sessions and high doses of
exercise of approximately 20 hours.
These characteristics have been
reported to be associated with better
outcomes in trials of exercise therapies for patients with low back
pain.22 In addition, experienced
therapists received structured training in the 2 interventions from the
same experts who trained therapists
in trials that found that both interventions were effective in the treatment of patients with low back
pain.27,31 Finally, this study was
developed, registered, and published
a priori with the design informed by
experts in the field who have published key literature on this
topic.11,33
The only previously published trial
similar to the current trial, that of
Critchley et al,21 also showed no differences in outcome between motor
control exercises and graded activity
at 6, 12, and 18 months after intervention. That study had a 3-group
design and included a motor control
treatment group, a graded activity
treatment group, and a treatment
group that received manual therapy
plus home exercise. As the interventions in the study by Critchley
et al were performed in a group,
not individually, and more than 22%
of the study participants were lost
to follow-up, direct comparison with
our results needs to be made with
caution. Despite the trial differences,
the study by Critchley et al showed
that graded activity was more costeffective than motor control exercise, as graded activity had slightly
greater effects and lower health care
costs. Our findings are in line with
systematic reviews of exercise therMarch 2012
apies that concluded there is no evidence to suggest one form of exercise therapy is better than another
when applied to a nonspecific low
back pain group.4,5 These reviews,
however, suggested that the quality
of exercise implementation may be
important (eg, better results were
observed in exercise programs that
were individually designed and delivered with supervision).22
Although the results of our study suggest that there is no difference
between the 2 exercise therapies for
patients with chronic nonspecific
low back pain, these results do not
preclude the possibility that subgroups of patients who respond better to each of these interventions
may exist. Therefore, it is possible
that patients with motor control deficits at baseline, such as decreased
activation of the transversus abdominis muscle and decreased trunk proprioception, would benefit more
from a motor control intervention
and that patients with higher fearavoidance, kinesiophobia, and lower
fitness levels would benefit more
from a graded activity approach.
Analyses to clarify this issue are
ongoing and form the basis of a secondary analysis of our data, for
which the sample size of this study
was calculated. Further information
on effect modifiers that are plausible
and yet to be tested are listed in our
previously published protocol.23
A limitation of this study was the fact
that more participants were lost to
follow-up in one treatment group
than the other (4 in the graded activity group and 10 in the motor control
exercise group). Although no clear
reasons for loss to follow-up were
identified, we cannot exclude the
possibility that treatment may have
influenced the disparity in loss to
follow-up. However, due to the
small overall loss to follow-up (less
than the recommended 15%),50 we
believe it minimally affected the
results of this study. Another limitation of this study was the fact that
we did not include a no-treatment
control group that would allow
the evaluation of the absolute
effects of both interventions. However, previously published systematic reviews of both interventions
have demonstrated that both are
effective: achieving better reductions in pain and disability than no
treatment or minimal intervention
(eg, waiting list or general practitioner care).4,5 Finally, our trial
included only self-reported measures
of function, and it may be that objective measurement of function or
physical activity would have provided a different result.
Given the results of this trial, we suggest that local factors should direct
clinician choice between the forms
of exercise we tested. Both forms of
exercise are new developments in
the rehabilitation field, and so a clinicians familiarity with either form
would be a prime consideration in
treatment selection. The physical
therapists who administered the
motor control exercises in this trial
had access to real-time ultrasound to
guide treatment selection and to
assist the patient with learning the
appropriate exercise. The limited
availability of this equipment and
lack of familiarity in using this specific technology may be limitations
of this form of exercise, as not all
physical therapy clinics contain diagnostic ultrasound machines. In our
study, one physical therapist chose
not to use the ultrasound machine,
demonstrating the lack of familiarity
of therapists with this technology,
which has been proven to improve
patients outcomes.29
In conclusion, the results of this trial
suggest that motor control exercises
and graded activity have similar
effects in reducing pain and disability and in increasing function, global
impression of change, and quality of
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Physical Therapy f
375

life when applied to a nonspecific
chronic low back pain group. These
results are similar to those of clinical guidelines that recommend that
no exercise therapy is superior to
another. We recommend that in clinical practice therapists identify their
area of expertise and treat their
patients accordingly.
Dr Macedo, Dr Latimer, Dr Maher, Dr
Hodges, Dr Nicholas, and Mr Stafford provided concept/idea/research design. Dr
Macedo, Dr Latimer, Dr Maher, Dr Hodges,
Dr McAuley, and Dr Stanton provided writing. Dr Macedo, Dr Hodges, Dr McAuley,
Mr Stanton, Dr Stanton, and Mr Stafford
provided data collection. Dr Macedo, Dr
Maher, Dr Hodges, Dr McAuley, and Mr
Stafford provided data analysis. Dr Macedo,
Dr Latimer, Dr Maher, Dr Hodges, Dr McAuley, Mr Stanton, and Dr Stanton provided
project management. Dr Latimer, Dr Maher,
and Dr Hodges provided fund procurement.
Dr Latimer, Dr Hodges, and Ms Tonkin
provided institutional liaisons. Dr Macedo
provided clerical support. Dr Macedo, Dr
Latimer, Dr Maher, Dr Nicholas, Ms Tonkin,
Mr Stanton, and Dr Stanton provided consultation (including review of manuscript
before submission).
The content of this article was presented
at the International Low Back Pain Forum
for Research in Primary Care, March 15
18, 2011, Melbourne, Victoria, Australia;
the Annual Meeting of the International
Society for the Study of the Lumbar Spine,
June 14 18, 2011, Gothenburg, Sweden;
and the Australian Physiotherapy Association
Conference, October 2730, 2011, Brisbane, Queensland, Australia.
The trial protocol was approved by the
University of Sydney (approval 122006/
9704), the University of Queensland Human
Research Ethics Committees (2007001583),
and the Royal Brisbane and Womens Hospital Ethics Board (2007001583).
This trial received funding from Australias
National Health and Medical Research Council. Dr Latimers and Dr Mahers research
fellowships are funded by the Australian
Research Council. Dr Hodges research fellowship is funded by Australias National
Health and Medical Research Council.
Clinical trial registration: ACTRN12607000432415.
DOI: 10.2522/ptj.20110290
376
Physical Therapy
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Volume 92 Number 3
Physical Therapy f
377
Effect of Motor Control Exercises Versus Graded

Activity in Patients With Chronic Nonspecific Low
Back Pain: A Randomized Controlled Trial
Luciana Gazzi Macedo, Jane Latimer, Christopher G.
Maher, Paul W. Hodges, James H. McAuley, Michael K.
Nicholas, Lois Tonkin, Chris J. Stanton, Tasha R.
Stanton and Ryan Stafford
PHYS THER. 2012; 92:363-377.
Originally published online December 1, 2011
doi: 10.2522/ptj.20110290
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Correction
Macedo LG, Latimer J, Maher CG, et al. Effect of motor control exercises versus graded activity
in patients with chronic nonspecific low back pain: a randomized controlled trial. Phys Ther.
2012;92:363377.
An incorrect graph was used in Figure 3 of the article by Macedo et al. Figure 3 has been corrected in the
online versions of this article. The corrected Figure 3 is shown below:
[DOI: 10.2522/ptj.20110290.cx]
April 2012
Correction 4.12.indd 631
Volume 92 Number 4 Physical Therapy 631
3/8/12 1:25 PM

Phys Ther 2012 Macedo 363 77

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Effect of Motor Control Exercises Versus Graded

Activity in Patients With Chronic Nonspecific Low

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A correction has been published for this article. The

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Background. Motor control exercises to improve control and coordination of

Setting. The study was conducted in primary care settings.

Interventions. Patients were randomly assigned to receive either motor control

L.G. Macedo, PT, PhD, Common

Limitations. Clinicians could not be blinded to the interventions.

Post a Rapid Response to

Motor Control Versus Graded Activity for Low Back Pain

upervised exercise therapies

Motor Control Versus Graded Activity for Low Back Pain

week?) or question 8 (During the

Exclusion criteria were:

We used a red flag checklist to

tions that would prevent safe participation in exercise.

The Bottom Line

What new information does this study offer?

If youre a patient or a caregiver, what might these

Motor Control Versus Graded Activity for Low Back Pain

Motor Control Versus Graded Activity for Low Back Pain

Principles of the Interventions

Reinforce wellness behavior and ignore illness

Education regarding pain system and reassurance

Education regarding ergonomic factors and body

Generalized (whole body) exercises with

Generalized (whole body) exercises without

Focus on correct activation of muscles

Correction of motor patterns

Correction of provocative movement patterns

Progression to functional activities

Use feedback (eg, ultrasound, electromyography,

Check mark indicates principle applies to the intervention.

months. Because of a printing error,

(Have you experienced any side

Motor Control Versus Graded Activity for Low Back Pain

ing the standard deviation estimates

Motor Control Versus Graded Activity for Low Back Pain

Low back pain of less than 3 months duration

Not expected to continue residing in the study area

Less than moderate pain or disability on question 7 or 8 of the SF-36a

Pain in a location other than the lower back

Nerve root compromise

Younger than 18 or older than 80 years of age

Suspected or confirmed serious pathology such as fracture or cancer

History of back surgery

Judged not fit to perform physical exercise

Not able to contact patient

Already undergoing treatment

SF-3636-Item Short-Form Health Survey questionnaire.

(44%), some of the time (19%), a

(SD0.7), respectively, for therapist

Motor Control Versus Graded Activity for Low Back Pain

355 patients referred

Motor control exercise group=86

Graded activity group=86

Median=13 (5.25) treatments completed

Median=12 (4.25) treatments completed

Care providers performing the intervention

82 (95.3%) were followed up at 2 months

Lost to follow-up (n=10; 6 withdrew from