Research Report

Motor Control Exercises, Sling

M. Unsgaard-Tøndel, MSc, is a PhD
candidate in the Department of
Public Health and General Practice,
Faculty of Medicine, Norwegian Uni-
versity of Science and Technology,
Trondheim, Norway. Mailing ad-
dress: Department of Public Health
and General Practice, Norwegian
University of Science and Technol-
ogy, Faculty of Medicine, Medisinsk
Teknisk Forskningssenter, 7489
Trondheim, Norway. Address all
correspondence to Mrs Unsgaard-
Tøndel at: monica.unsgaard.
tondel@ntnu.no.
A.M. Fladmark, MSc, is Research
Assistant, Department of Public
Health and General Practice, Fac-
ulty of Medicine, Norwegian Uni-
versity of Science and Technology.
Ø. Salvesen, MSc, is Assistant
Professor, Department of Cancer
Research and Molecular Medi-
cine, Faculty of Medicine, Nor-
wegian University of Science and
Technology.
O. Vasseljen, PhD, is Associate
Professor, Department of Public
Health and General Practice, Fac-
ulty of Medicine, Norwegian Uni-
versity of Science and Technology.
[Unsgaard-Tøndel M, Fladmark
AM, Salvesen Ø, Vasseljen O. Mo-
tor control exercises, sling exer-
cises, and general exercises for pa-
tients with chronic low back pain:
a randomized controlled trial with
1-year follow-up. Phys Ther. 2010;
90:1426 –1440.]
© 2010 American Physical Therapy
Association
Exercises, and General Exercises for
Patients With Chronic Low Back Pain:
A Randomized Controlled Trial With
1-Year Follow-up
Monica Unsgaard-Tøndel, Anne Margrethe Fladmark, Øyvind Salvesen,
Ottar Vasseljen
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 Nu-
meric 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 exer-
cises for chronic low back pain.

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1426 f Physical Therapy Volume 90 Number 10 October 2010


N
onspecific low back pain
(LBP) is a major public health
problem in industrialized soci-
eties, with lifetime prevalence be-
tween 60% and 85%.1 Reviews point
to beneficial effects of supervised
exercises in people with chronic
LBP,2,3 but there is no clear evidence
that any specific type of exercise is
better than other forms of exer-
cise.4 – 6 The term “specific exercise”
has been used to describe quite dif-
ferent types of exercises, such as sta-
bilization exercises and abdominal
drawing-in maneuver (ADIM),7,8 indi-
vidualized exercises,9 supervised ex-
ercises,10 and even what appear to
be general exercises.11,12 It is plausi-
ble, therefore, that specifically tar-
geted exercises with potential bene-
fits relative to more general exercises
may be concealed when different
studies are summarized in reviews.
Motor control exercises for the deep
trunk muscles were introduced for
patients with chronic LBP based on
evidence of motor control dysfunc-
tion, including delayed onset of ac-
tivity in the transversus abdominis
(TrA) and internal oblique abdomi-
nal muscles13 and segmental hyper-
trophy of the lumbar multifidus mus-
cle.14 Early studies that tried to target
these discrepancies with specific in-
terventions15–19 provided promising
evidence for beneficial effects. A re-
cent placebo-controlled study of pa-
tients with chronic LBP confirmed
that motor control exercises pro-
duced improvements in both activity
and patients’ impressions of recov-
Available With
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• Audio Abstracts Podcast
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October 2010
Exercises for Patients With Chronic Low Back Pain
ery in both the short term and long ferent effects compared with either
term, but that the improvements were high-load motor control exercises
small.20 Another study that added spe- potentially stimulating both local
cific stabilization exercises to general and global supporting lumbar mus-
exercises, however, did not provide cles when performed in neutral
any evidence of beneficial effects on spine positions or general exer-
pain and disability.21 According to cises designed for strength (force-
Richardson et al,22 the first step in re- generating capacity) and flexibility.
habilitating motor skill is to train the
patient to cognitively contract the The purpose of this study was to
deep trunk muscles independently. compare supervised low-load (pri-
The ADIM has been emphasized in the marily ADIM) motor control exer-
early phase of exercises to regain con- cises and supervised high-load sling
trol of the deep abdominal muscles exercises with general exercises in
and provide stability to the lumbar the early phase of rehabilitation for
spine before progressing to heavier patients with chronic LBP. Primary
exercises. This low-load exercise ap- outcome measures were pain after
proach has been met with consider- intervention and at a 1-year follow-up.
able criticism by other authors who Secondary outcome measures were
argued that stability of the spine disability, fear avoidance, and trunk
should be targeted by forceful abdom- flexibility after intervention.
inal muscle contraction.23,24 Whether
the ADIM has a direct effect on pain Method
and function and how the effect of Setting and Participants
such low-load exercises compares A randomized controlled trial with 3
with that of high-load or general exer- intervention groups was conducted,
cises in the early phase of rehabili- with participants recruited from gen-
tation have not been studied. Hypo- eral practitioners or physical thera-
thetically, low-load motor control pists (29/109) and by announcement
exercises targeting local supporting to employees at a large local hospital
lumbar muscles may produce dif- (80/109) in Norway. The employees
The Bottom Line
What do we already know about this topic?
Supervised exercises benefit patients with chronic nonspecific low back
pain; however, the most effective type of exercise remains unknown.
What new information does this study offer?
This study compared motor control exercises, sling exercises, and general
exercises in the early phase of rehabilitation for patients with chronic non-
specific low back pain. A course of 8 treatments did not show any overall
group differences in pain, self-reported activity limitation, or function.
If you’re a patient, what might these findings mean
for you?
These 3 exercise programs appear to be equally effective, so you should
choose a program based on such issues as program availability, the costs
of each program, and your preferences.
Volume 90 Number 10 Physical Therapy f 1427
Exercises for Patients With Chronic Low Back Pain

and participants recruited from the

health care providers had similar pain
levels and ages. The participants in-
cluded were 19 to 60 years of age with
chronic nonspecific LBP of at least 3
months’ duration and with pain at pre-
sentation between 2 and 10 on the
Numeric Pain Rating Scale (NPRS) (0 –
10).25 Participants were excluded for
the following reasons: previous back
surgery, radiating pain below the knee
or neurologic signs from nerve-root
compression, systemic or widespread
pain, overweight preventing ultra-
sound imaging, pregnancy, diagnosed
psychiatric disease, sick leave for more
than 1 year, recipient of disability ben-
efits, unresolved social security or in-
surance problems, or insufficient lan-
guage capabilities. Written informed
consent was given by all participants
before randomization.

Randomization and
Interventions
Participants were randomly assigned
to 1 of 3 treatment groups: (1) those
who received low-load, individually
instructed, ultrasound-guided motor
control exercises (MCE group);
(2) those who received high-load, in-
dividually instructed sling exercises
(SE group); or (3) those who received
general exercises (GE group). Eligibil-
ity was assessed by a research physical
therapist, and enrolled patients were
randomly assigned to groups after the
pretreatment assessment. The ran-
domization was administered by an
independent study secretary via tele-
phone. The secretary consecutively re-
ported group allocation for included
participants from a list of random
numbers between 0 and 1 that were
computationally generated. Partici-
pants with numbers in the lower third
of the interval were assigned to the
MCE group, those in the middle third
of the interval were assigned to the SE
group, and those in the upper third of
the interval were assigned to the GE
Figure 1. group. The column of random num-
Exercise interventions in the study: (A) motor control exercises, (B) sling exercises, bers was arbitrarily subdivided into
and (C) general exercises. variable blocks of 3 to 9 to obtain even

1428 f Physical Therapy Volume 90 Number 10 October 2010


distribution of participants in the
groups.
The participants in all treatment
groups attended treatment once a
week for 8 weeks. The attendance at
weekly treatment sessions was re-
corded, but adherence to home ex-
ercise was not recorded. All partici-
pants were encouraged to stay active
in their daily life, as recommended
by systematic reviews on advice for
management of LBP.26 In addition, all
participants received a booklet with
general information on LBP provided
by the Norwegian Network of Back
Pain (http://www.formi.no; in Nor-
wegian) that also emphasized bene-
fits of varied physical activity for non-
specific LBP. Participants were not
allowed to receive other treatment for
LBP during the intervention period.
Motor control exercises. The mo-
tor control exercise intervention is
shown in Figure 1A. The motor con-
trol treatments lasted 40 minutes and
took place in an outpatient clinic. The
low-load motor control exercises were
individualized and taught by a spe-
cially trained physical therapist ac-
cording to a protocol on therapeutic
exercise for lumbopelvic stabiliza-
tion27 and ultrasound imaging.28,29
Ultrasound imaging was used as both a
teaching tool and an evaluation tool
(separate substudy). Patients with mo-
tor control deficits may benefit from
visual feedback of muscle function
from ultrasound imaging.30 Ultrasound
imaging is increasingly used among cli-
nicians to retrain motor control in the
deep abdominal muscles.
The low-load motor control exercises
focused on isolated control and activ-
ity of the TrA during the ADIM.22 The
aim of the ADIM was to voluntary ac-
tivate TrA thickening and lateral slide
while the internal oblique and exter-
nal oblique abdominal muscles re-
mained relatively unchanged. The ex-
ercises were executed with low effort
and with relaxed respiration and were
October 2010
Exercises for Patients With Chronic Low Back Pain
continuously monitored by direct ob-
servation of respiration and by real-
time b-mode ultrasound imaging of su-
perficial and deep muscle activity.
Activity in the abdominal muscles was
visualized on the ultrasound screen for
each participant and used for feedback
in all treatment sessions. Participants
also were instructed in pelvic-floor
and multifidus muscle contractions.
Furthermore, a goal was to obtain con-
trolled co-contraction of the TrA, the
deep fibers of the multifidus muscle,
and the pelvic-floor muscles while
keeping other muscles relaxed. Partic-
ipants who achieved isolated activity
of the TrA in the supine position pro-
gressed to activation of the TrA simi-
larly in sitting and standing positions.
Toward the end of the intervention
period, the participants were in-
structed to incorporate the ADIM
into activities of daily living. Written
instruction to carry out the ADIM at
home was provided, and participants
were encouraged to perform 10
pain-free contractions 2 to 3 times
per day, holding each contraction for
10 seconds.22
Sling exercises. The sling exercise
intervention is shown in Figure 1B.
The participants in this group were
instructed individually by a specially
trained physical therapist. The exer-
cises were chosen from a predefined
set of back exercises in slings on the
basis of an assessment of each par-
ticipant’s ability to keep the lumbar
spine stable in the neutral position
through a range of leg and arm posi-
tions and movements (Appendix 1).
The sling method for dosing lum-
bopelvic exercises has been assessed
in combination with other treatment
modalities in earlier studies.18,31 Un-
loading elastic bands were attached
to the pelvis to help participants
maintain the neutral spine position
at all times and for exercises to
progress without pain. Exercise pro-
gression was achieved by gradually
reducing the elastic band support.
Volume 90
The supported position where the
participants could no longer main-
tain the neutral spine position was
used as the baseline for further exer-
cise progression. By placing the par-
ticipants in demanding but pain-free
positions and asking them to hold
the spine in neutral, the aim was to
activate the deep and superficial sta-
bilizing trunk muscles (local and
global muscles). When weakness,
pain, fatigue, or asymmetry was iden-
tified, this position served as starting
point for training and further pro-
gression. The number of repetitions
and sets was individually adjusted ac-
cording to pain and fatigue (Appen-
dix 2). The sling exercises were per-
formed for 40 minutes once a week
in a physical therapy clinic.
General exercises. The general
exercise intervention is shown in
Figure 1C. This group received gen-
eral trunk strengthening and stretch-
ing exercises, as recommended in the
management of nonspecific LBP.21,32
Exercises were instructed by a phys-
ical therapist and performed in small
groups of 2 to 8 people. Exercises
performed were, for instance, trunk
extension, flexion, and rotation with
resistance and stretching of trunk
and extremity muscles (Appendix 3).
The exercises were performed for 1
hour weekly in a local fitness center
with a traditional resistance appa-
ratus and with 10 repetitions in 3
sets.33,34 The exercise instructor su-
pervised each participant and indi-
vidually directed and adapted the
exercise performance when needed.
The physical therapists were experi-
enced in the exercise methods
applied. Participants in all treatment
groups received home exercises for
flexibility when considered necessary.
Outcome Measures
Self-reported current pain was the
main outcome measure and was
rated using the NPRS (0 –10).25 The
strongest experienced pain in the
Number 10 Physical Therapy f 1429
Exercises for Patients With Chronic Low Back Pain
Table 1.
Characteristics of Participants (n⫽109) in the 3 Intervention Groups for Background and Outcome Variables at Baselinea
Variable
Sex, male/female, n
Age (y)
Body mass index, kg/m2
Height (cm)
Weight (kg)
Low back pain, years since first episode,
median (interquartile range)
NPRS (0–10), present at moment
NPRS (0–10), strongest last month
ODI (0–100)
Fingertip-to-Floor Test
FABQ, physical activity
FABQ, work
a
Data are mean (SD) unless otherwise denoted. MCE group received low-load motor control exercises, SE group received high-load sling exercises, and GE
group received general exercises. NPRS⫽Numeric Pain Rating Scale, ODI⫽Oswestry Disability Index, FABQ⫽Fear-Avoidance Beliefs Questionnaire.
previous 4 weeks also was recorded
using the NPRS. The Oswestry Dis-
ability Index (ODI), modified ver-
sion,35 was used to assess disability,36
also termed “self-reported activity lim-
itation,” and the total score was ex-
pressed as a percentage. The Fear-
Avoidance Beliefs Questionnaire
(FABQ)37 was used to address nega-
tive beliefs that can contribute to
prolonged disability.38 The Fingertip-
to-Floor Test39 was used to examine
the participants’ ability to bend for-
ward in standing by measuring the
distance between the longest finger-
tip and the floor. Lower scores are
associated with decreased symptoms
for all outcome measures.
All outcome measures were applied
at baseline and after the intervention
period. Although the baseline assess-
ment was performed blinded, the
physical therapist conducting the post-
intervention evaluation was not
blinded to treatment group allocation.
At the 1-year follow-up (14 months af-
ter randomization), the participants
answered a questionnaire on pain and
health care utilization. The person
who analyzed the data was blinded to
group assignment.
1430 f Physical Therapy Volume 90
MCE Group
(nⴝ36)
7/29
40.9 (11.5)
24.9 (3.1)
171.4 (7.7) 172.6 (7.7)
73.3 (11.6)
6.0 (2–19)
3.3 (1.3)
6.0 (2.0)
19.4 (7.3)
11.9 (13.0)
7.8 (5.2)
13.2 (9.2)
Data Analysis
This study was part of a larger
project studying the effects of spe-
cific low back exercises on symp-
toms and underlying neuromuscular
mechanisms in which the sample size
was determined to detect between-
group changes in feed-forward ac-
tivity in the TrA with an estimated
effect size of 0.8 (unpublished re-
search). We performed an intention-
to-treat analysis, and used mixed linear
models to estimate mean scores, to
estimate baseline-adjusted between-
group differences, and to test whether
baseline-adjusted group differences at
posttest were significantly different.
Participants completing fewer than 6
of the 8 treatment sessions were ex-
cluded from postintervention evalua-
tion, but their baseline data were in-
cluded in the mixed models analysis.
The statistical analyses were per-
formed with SPSS version 17.0* and
NCSS 2007.† The level for statistical
significance was set at Pⱕ.05.
* SPSS Inc, 233 S Wacker Dr, Chicago, IL
60606.
†
NCSS, 329 North 1000 East, Kaysville, UT
84037.
Number 10
SE Group GE Group
(nⴝ36) (nⴝ37)
13/23 13/24
43.4 (10.2) 36.0 (10.3)
24.9 (3.1) 24.3 (2.8)
171.2 (8.7)
74.5 (11.6) 71.1 (9.9)
9.0 (2–15) 6.0 (3.5–11.5)
3.6 (1.7) 3.3 (1.9)
6.7 (2.4) 5.9 (1.8)
22.3 (12.1) 20.8 (9.8)
15.0 (12.5) 8.8 (9.7)
8.8 (5.6) 9.2 (5.4)
14.4 (10.9) 13.2 (8.7)
Role of the Funding Source
The Norwegian Fund for Postgradu-
ate Training in Physiotherapy fi-
nanced the study. The funding orga-
nization had no authority over or
input into any part of the study. Sling
exercise equipment was provided
without obligations by Redcord AS.
Results
Recruitment and inclusion of par-
ticipants were performed between
January 2006 and September 2007.
After randomization, 36 patients
were allocated to the MCE group, 36
patients were allocated to the SE
group, and 37 patients were allo-
cated to the GE group (Tab. 1). All
participants were included in the sta-
tistical analyses, independent of
completion. One physical therapist
performed interventions for all pa-
tients allocated to the MCE group.
The sling exercise and general exer-
cise interventions were led by 4 al-
ternating physical therapists. In the
SE group, the therapists instructed
22, 8, 4, and 2 participants, respec-
tively. In the GE group, the 4 thera-
pists were continuously alternating.
Twelve of 80 participants who were
recruited by announcement at the
October 2010
 Exercises for Patients With Chronic Low Back Pain

Potentially eligible participants (n=120)

Enrollment

Excluded (n=11)
Not meeting inclusion criteria (n=10)

▼
Declined to participate (n=1)

▼
Randomized (n=109)
Allocation

▼ ▼ ▼
Motor control exercises (n=36) Sling exercises (n=36) General exercises (n=37)

≤5 sessions: 14% ≤5 sessions: 17% ≤5 sessions: 30%

6-8 sessions: 86% 6-8 sessions: 83% 6-8 sessions: 70%
▼ ▼ ▼
Follow-up
Follow-up Follow-up
Follow-up

1 treatment nonadherence
4 lost to follow-up
8 weeks (n=31 [86%])
1 year (n=30 [83%])
7 treatment nonadherence
3 withdrawals from the study
3 lost to follow-up
3 lost to follow-up
1 withdrawal from the study
8 weeks (n=30 [83%])
8 weeks (n=26 [70%])
1 year (n=34 [94%])
1 year (n=33 [89%])

▼ ▼ ▼
Analysis

Analyzed (n=36) Analyzed (n=36) Analyzed (n=37)

Figure 2.
Enrollment of patients and completion of study.

local hospital and 10 of 29 partici-
pants who were recruited from pri-
mary care dropped out during the
intervention period. Reasons for
dropouts during the intervention pe-
riod are shown in Figure 2. At the
1-year follow-up assessment, 2 peo-
ple in the MCE and GE groups each
and 1 person in the SE group did not
return the questionnaire. The people
who dropped out were compared
with those who completed the study
for initial score on background and
outcome variables at baseline, and
no significant differences were
found, as indirectly evident in Tables
1 and 2. The interventions were car-
ried out as planned and are de-
scribed in the “Method” section.
Postintervention and
1-Year Follow-up Assessments
No significant differences were found
among the groups at the postinterven-
tion assessment for pain, activity limi-
tation (ODI), the FTF, fear-avoidance
beliefs for physical activity, or fear-
avoidance beliefs for work (Tab. 2,
Fig. 3). Mean current pain group dif-
ferences (95% confidence interval)
after intervention, adjusted for base-
line score, were 0.3 (⫺0.7 to 1.3) in
the MCE group compared with the
SE group, 0.7 (⫺0.6 to 2.0) in the SE
group compared with the GE group,
and 1.0 (⫺0.1 to 2.0) in the MCE
group compared with the GE group
(P⫽.19 for overall group difference,
Tab. 2). At the 1-year follow-up as-
sessment, group differences in mean
current pain adjusted for baseline
score were 0.4 (⫺0.7 to 1.4) in the
MCE group compared with the SE
group, 0.3 (⫺0.8 to 1.4) in the SE
group compared with the GE group,
and 0.7 (⫺0.3 to 1.7) in the MCE
group compared with the GE group
(P⫽.42 for overall group difference).
Mean adjusted group differences in ac-
tivity limitation score (ODI) after inter-
vention were 0.6 (⫺4.3 to 5.4) in the

October 2010 Volume 90 Number 10 Physical Therapy f 1431

Exercises for Patients With Chronic Low Back Pain

Table 2.
Estimated Mean (SD) Unadjusted Scores for the Different Treatment Groups and Times and Estimated Mean (95% Confidence
Interval) Baseline-Adjusted Group Differences After Intervention as Given by the Mixed Linear Modelsa
Mean Outcome Adjusted Mean Group Differenceb
MCE Group SE Group GE Group MCE Group vs SE Group vs MCE Group vs
Variable (nⴝ36) (nⴝ36) (nⴝ37) SE Group GE Group GE Group Pc
d
Pain

Current

Baseline 3.31 (1.42) 3.61 (1.75) 3.30 (1.74)

2 mo 1.76 (1.54) 2.34 (2.26) 2.73 (2.32) 0.27 (⫺0.73 to 1.27) 0.71 (⫺0.55 to 1.97) 0.97 (⫺0.08 to 2.03) .19

1y 2.01 (1.94) 2.70 (2.22) 2.66 (2.03) 0.39 (⫺0.65 to 1.44) 0.27 (⫺0.83 to 1.36) 0.66 (⫺0.34 to 1.66) .42

Strongest

Baseline 6.25 (1.99) 6.39 (2.32) 6.22 (2.03)

2 mo 4.09 (2.08) 4.80 (2.41) 5.26 (2.74) 0.57 (⫺0.57 to 1.71) 0.63 (⫺0.74 to 2.01) 1.20 (⫺0.03 to 2.44) .15
e
Disability

Baseline 19.44 (8.38) 22.28 (11.22) 20.84 (9.43)

2 mo 12.78 (7.62) 16.18 (10.88) 17.75 (9.63) 0.56 (⫺4.25 to 5.37) 3.02 (⫺2.44 to 8.47) 3.58 (⫺0.47 to 7.63) .21

Trunk flexionf

Baseline 11.94 (10.86) 15.00 (10.86) 8.78 (10.86)

2 mo 7.44 (10.86) 11.13 (10.86) 7.57 (10.86) 0.6 (⫺3.2 to 4.4) 2.7 (⫺1.3 to 6.6) 3.3 (⫺0.7 to 7.3) .23

FABQ, physical
activityg

Baseline 7.75 (5.35) 8.78 (5.82) 9.22 (5.03)

2 mo 7.31 (4.22) 6.76 (5.37) 8.60 (5.14) ⫺1.58 (⫺4.00 to 0.84) 1.40 (⫺1.25 to 4.05) ⫺0.18 (⫺2.42 to 2.07) .41
h
FABQ, work

Baseline 13.19 (9.18) 14.46 (10.26) 13.53 (9.64)

2 mo 11.86 (9.67) 12.72 (9.46) 12.44 (8.80) ⫺0.40 (⫺3.81 to 3.01) 0.65 (⫺2.70 to 4.00) 0.25 (⫺2.74 to 3.24) .93
a
MCE group received low-load motor control exercises, SE group received high-load sling exercises, and GE group received general exercises.
b
Group-wise comparison of estimated mean posttest scores adjusted for baseline, contrast estimates. Positive value indicates greater improvement in first
group.
c
Overall between-groups difference in score after intervention, adjusted for baseline. The P values refer to F tests of whether estimated group differences
were significantly different from zero.
d
Pain as assessed with the Numeric Pain Rating Scale. Score range: 0 (“no pain”) to 10 (“worst imaginable pain”). Strongest pain indicates worst pain
experienced during the last 4 weeks.
e
Disability as assessed with the Oswestry Disability Index. Score range: 0 (no activity limitation) to 100 (full activity limitation) for the 10 functions screened.
f
Trunk flexion as assessed with the Fingertip-to-Floor Test (in centimeters).
g
Fear-Avoidance Beliefs Questionnaire for physical activity. Score range: 0 (no fear) to 24 (maximum fear).
h
Fear-Avoidance Beliefs Questionnaire for work. Score range: 0 (no fear) to 42 (maximum fear).

MCE group compared with the SE
group, 3.0 (⫺2.4 to 8.5) in the SE
group compared with the GE group,
and 3.6 (⫺0.5 to 7.6) in MCE group
compared with the GE group (P⫽.21
for overall group difference).
Of the participants, 48% in the MCE
group, 41% in the SE group, and 50%
in the GE group sought therapy for
LBP the year after intervention
(Tab. 3), and 24% in the MCE group,
31% in the SE group, and 42% in the
GE group used medication because of
LBP the year after intervention. One
participant in the SE group reported
adverse effects of the intervention and
withdrew from the study.
Discussion
This study compared motor control
exercises, sling exercises, and general
exercises in the early phase of rehabil-
itation for patients with chronic non-
specific LBP. A course of 8 treat-
ments did not show any overall
group effects in pain, disability, and
fear-avoidance beliefs. A 10-unit (per-
cent) change in ODI score40 and a
2-point change in NPRS score (0 –10)
have been suggested as minimum im-
portant changes for patients25,40,41
and have been interpreted to repre-
sent clinically relevant between-group
differences.3 The observed mean ef-
fects in this study did not reach these
levels. However, we cannot exclude
that motor control exercises are favor-
able for reducing pain relative to gen-
eral exercises because the clinically
important difference for pain40 was
included in the confidence interval

1432 f Physical Therapy Volume 90 Number 10 October 2010

 Exercises for Patients With Chronic Low Back Pain

Figure 3.
Mean scores, with 95% confidence intervals, for the outcome measures in each of the 3 intervention groups: (A) pain scores (Numeric
Pain Rating Scale [NPRS]) before and after intervention and at the 1-year follow-up, (B) activity limitation scores (Oswestry Disability
Index) before and after intervention, and (C) distance between fingertip and floor before and after intervention. MCE group received
low-load motor control exercises, SE group received high-load sling exercises, and GE group received general exercises.

Table 3.
Health Care Utilization Before, During, and After (Follow-up Period) the Interventiona

Variable MCE Group SE Group GE Group

Low back pain therapyb

Before 26 (75%) 26 (72%) 21 (57%)

After 14 (48%) 12 (41%) 12 (50%)

Low back pain medication

Before 10 (32%) 8 (27%) 6 (24%)

During 6 (19%) 5 (17%) 7 (27%)

After 7 (24%) 9 (31%) 10 (42%)

a
MCE group received low-load motor control exercises, SE group received high-load sling exercises, and GE group received general exercises.
b
Low back pain treatment administered by a physician, physical therapist, chiropractor, osteopath, or acupuncture practitioner.

October 2010 Volume 90 Number 10 Physical Therapy f 1433

Exercises for Patients With Chronic Low Back Pain
(Tab. 2). The results from this study
gave no evidence of added benefit of
specific exercises over general exer-
cises for people with chronic LBP.
Certain limitations apply to this study.
Sample size was calculated based on
desired effects on onset of muscle ac-
tivity in the TrA (unpublished re-
search). With the reported effect sizes
for pain (Tab. 2), the study would have
needed 59 participants in each group
to declare a difference as statistically
significant at the P⫽.05 level (80%
power). Still, for clinically important
changes in pain of 2 points on the
NPRS, the study had acceptable power
(⬎80%). Blinding is practically impos-
sible in exercise interventions. This
limitation was mainly critical for the
fingertip-to-floor measurements in
this study because pain, disability,
and fear avoidance were assessed by
the participants without interfer-
ence of the researchers. Adherence
to allocated treatment is important
for sound comparison of interven-
tions, which was the reason for ex-
cluding participants who attended
fewer than 6 treatment sessions from
the postintervention evaluation. This
exclusion of participants may have
created biased results. However,
the baseline data for these individu-
als were included in the mixed
model analysis. Twice as many par-
ticipants dropped out of the GE
group compared with the other ex-
ercise groups. If most of the drop-
outs in the GE group were due to
lack of effect, this factor would un-
derestimate the between-groups dif-
ferences (ie, reduce the difference
between the GE group and the MCE
and SE groups).
Some caution should be advocated in
generalizing the results to clinical pop-
ulations. A large proportion of partici-
pants were recruited directly by an-
nouncement at a local hospital (73%).
Although participants who were re-
cruited directly were not differenti-
ated by pain symptoms from those
1434 f Physical Therapy Volume 90
who were recruited from health care
providers, there was a difference in
dropout rate (15% versus 40%, respec-
tively). This difference might have
been due to a greater degree of moti-
vation among the participants who
initiated participation themselves. The
exercise interventions were carried
out to reflect clinical practice, which
strengthens generalization and inter-
pretation of the results.
Distress and fear-avoidance beliefs
can contribute to the maintenance of
LBP.42 Exercises may lessen the be-
havioral, cognitive, and affective as-
pects of chronic nonspecific LBP,43
but no change in fear-avoidance be-
liefs was observed in this study.
Motor control exercises for people
with LBP consist of several stages,
from cognitive awareness and isolated
activation of deep trunk muscles to
control of movement and stability in
more-complex functional tasks of
daily living.22 Motor control theories
imply that functionally oriented and
varied exercise should be incorpo-
rated early in rehabilitation.44,45 The
objective of the motor control exer-
cise intervention in this study was to
increase activity and voluntary control
of the deep abdominal muscles. Visual
feedback from real-time ultrasound
imaging was used to optimize perfor-
mance, which was further empha-
sized through individual instruction
and encouragement by the therapist
operating the ultrasound device. This
intervention may be regarded as early-
stage exercises in a more comprehen-
sive motor control exercise program,
with little focus on integrating the ex-
ercises into everyday activities. It is
possible that a more comprehensive
approach encompassing all aspects of
motor control retraining could pro-
duce different results.
The effects of motor control exer-
cises in people with chronic LBP
have been investigated in a few stud-
ies. The MCE group versus GE group
Number 10
differences in the present study were
larger for pain and smaller for disabil-
ity relative to pooled effect sizes in a
review on motor control exercises
versus other forms of exercise.4 An
8-week program of motor control ex-
ercises resulted in better short-term
function, reduced pain, and improved
perceived effect relative to general ex-
ercises.7 Effect sizes (95% confidence
interval) for pain after 8 weeks and 1
year were 0.8 (0.1 to 1.6) and 0.3
(⫺0.6 to 1.3) in favor of motor control
exercises compared with general ex-
ercises on a scale of 0 to 10. Corre-
sponding effect sizes in the present
study were 1.0 (⫺0.1 to 2.1) and 0.6
(⫺0.4 to 1.7) in favor of motor control
exercises. The effect sizes were similar
despite a more extensive motor con-
trol exercise approach in the former
study. Costa et al20 compared a com-
prehensive motor control exercise
program with placebo ultrasound and
shortwave therapy. After 12 treat-
ments, motor control exercises had
beneficial effects on global impression
of recovery, activity, and activity limi-
tation. Improvement also was found in
pain intensity at 12 months but not at
2 and 6 months. The authors argued
that because the clinical improve-
ments were small, some patients and
clinicians may not consider these ef-
fects clinically worthwhile. The cited
studies and the present study support
the findings of systematic reviews that
motor control exercises4 and stabiliz-
ing exercises5 are not more effective
or only marginally more effective than
general exercises. However, a recent
review concluded that motor control
exercises were better than minimal
intervention in reducing pain in the
short term, intermediate term, and
long term by 10 to 15 points on a
100-point scale, but not better than
other forms of exercises.4
The sling exercise intervention ad-
dressed the ability to stabilize the
lumbar spine while moving the
lower extremities with unstable sup-
port. Both strength and muscle coor-
October 2010

dination were needed to maintain
the neutral spine position. No dis-
cernable difference in absenteeism
was found between a sling exercise
group and a general exercise group
in the only previous study of sling
exercises for people with LBP.46
Women with pelvic girdle pain after
pregnancy showed significantly
lower pain and improved function
after 20 weeks with a specific exer-
cise program in slings relative to or-
dinary physical therapy.18,19 Individ-
ual treatment program was based on
a clinical examination. Compared
with the present trial, a considerably
more extensive sling exercise pro-
gram was used in the study by Stuge
et al,18 including sling exercises at
home and motor control exercises
for the deep abdominal muscles. Pos-
sible additive effects of combining
high-load and low-load specific exer-
cises, as in the studies by Stuge and
colleagues,18,19 also should be inves-
tigated for nonspecific LBP.
The GE group served as control
group, and the general exercise in-
tervention was constructed to ad-
here to current evidence of best
practice,47,48 with advice and super-
vised activity that included strength-
ening and stretching exercises that
are central in LBP rehabilitation32,48
and with individual guidance by a
physical therapist when considered
necessary. The results indicate that
general exercises could be recom-
mended, similar to sling exercises and
motor control exercises, when aiming
to reduce pain and disability in the
early phase of LBP rehabilitation.
Motor control exercises are intended
to alter underlying neural mechanisms
shown to be associated with LBP. As
little as one session with muscle con-
traction practice can alter cortical ex-
citation49 and cause improvement in
deep abdominal muscle onset of activ-
ity.50 Isolated voluntary contractions
of the TrA have induced a shift in mo-
tor cortical representation of the TrA
October 2010
Exercises for Patients With Chronic Low Back Pain
toward that observed in individuals
who were healthy by as little as 2
weeks with motor skill training.51
Only marginal changes in muscle con-
traction properties (abdominal muscle
slide and thickness) during the ADIM
were observed in participants over the
intervention period in a separate sub-
study.52 There is a need to scrutinize
links between neural mechanisms and
symptoms to advance outcome mea-
sures in LBP research.
Patients with nonspecific LBP con-
stitute a heterogeneous group.6
Mechanism-based classification meth-
ods that can identify subgroups in
need of either movement or control
enhancement have been proposed.53,54
The specific exercises in the present
trial aimed to address muscle dysfunc-
tions,55,56 but subject-specific deficits
in neuromuscular control were not a
selection criterion. To date, classifica-
tion systems for LBP are insufficiently
supported by scientific evidence.57
Whether exercises tailored to deficits
in strength, flexibility, neural firing
patterns, or voluntary control of mus-
cles that stabilize the spine lead to en-
hanced clinical outcome needs to be
explored.
Conclusion
No significant group differences were
found in pain, disability, trunk flexibil-
ity, or fear-avoidance beliefs after 8
weeks of motor control exercises,
sling exercises, and general exercises
in patients with chronic nonspecific
LBP. However, confidence intervals
for improved outcome spanned clini-
cally important differences in favor of
the motor control exercise interven-
tion compared with the general exer-
cise intervention, meaning clinically
important additive effects of motor
control exercises cannot be excluded.
Dr Vasseljen provided concept/idea/
research design, fund procurement, facili-
ties/equipment, and institutional liaisons.
Mrs Unsgaard-Tøndel and Dr Vasseljen pro-
vided writing and project management. Mrs
Volume 90
Unsgaard-Tøndel and Ms Fladmark provided
data collection, participants, and clerical
support. Mrs Unsgaard-Tøndel, Mr Salvesen,
and Dr Vasseljen provided data analysis. Mrs
Unsgaard-Tøndel, Ms Fladmark, and Dr Vas-
seljen provided consultation (including re-
view of manuscript before submission).
The authors thank the Norwegian Fund for
Post-Graduate Training in Physiotherapy for fi-
nancing the study and the physical therapists
at the Multidisciplinary Back Clinic at St. Olav
University Hospital, Trondheim Physiotherapy
Clinic, and Elixia Fitness Centre, for conducting
patient treatments and Redcord AS for supply-
ing exercise equipment. They also thank Astrid
Woodhouse, Ingrid Riphagen, and Jan Ove
Rein for technical support and Jon Magnussen,
Stephen Lock, and Tor Inge Andersen for com-
menting on the manuscript.
The study was approved by the Regional
Ethics Committee.
The results of this study were presented at
the 7th Interdisciplinary World Congress on
Low Back and Pelvic Pain; November 9 –12,
2010; Los Angeles, California.
The Norwegian Fund for Post-Graduate Train-
ing in Physiotherapy financed the study.
The study was preregistered in ClinicalTrials.
gov with identifier NCT00201513.
This article was submitted December 21,
2009, and was accepted May 31, 2010.
DOI: 10.2522/ptj.20090421
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Exercises for Patients With Chronic Low Back Pain

Appendix 1.
Sling Exercises: (A) Bilateral Hip Extension With Unilateral Closed Chain, (B) Unilateral Hip Flexion With Contralateral Closed
Chain, and (C) Unilateral Hip Abduction With Contralateral Closed Chain

1438 f Physical Therapy Volume 90 Number 10 October 2010

 Exercises for Patients With Chronic Low Back Pain

Appendix 2.
Description of Interventions

The motor control and sling exercise interventions are both termed “specific stabilizing exercises” in this article.

Motor Control Exercises

The home exercises, as well as the exercises performed with therapist instruction, were individually adapted, and
the participants who managed to perform an isolated contraction of the transversus abdominis muscle were
instructed to perform co-contractions of deep abdominal and back muscles together with pelvic-floor contractions.
The participants received stretching exercises when considered necessary.

Sling Exercises
The sling exercises were based on a treatment method that aims at regaining normal functional movement patterns
in patients with musculoskeletal disorders by using high levels of neuromuscular activation (Kirkesolaa). Body
weight-bearing exercises, gradual increase of resistance (workload), and no pain or increase of existing pain are
central elements. This method includes testing procedures for neuromuscular function of the kinetic chains and the
integration of local and global muscle function. The sling exercises in this study were built upon principles described
in Fysioterapeuten (the Norwegian journal of physical therapy)a but with only manual handling of the slings.
a
Kirkesola G. Neurac: a new treatment method for chronic musculoskeletal pain [abstract in English]. Fysioterapeuten. 2009;76(12):10.

October 2010 Volume 90 Number 10 Physical Therapy f 1439

Exercises for Patients With Chronic Low Back Pain

Appendix 3.
General Exercises: (A) Trunk Extension, (B) Leg Curl, and (C) Arm Extension

1440 f Physical Therapy Volume 90 Number 10 October 2010

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.