Mechanisms of Specific Trunk Exercises in Low Back Pain
Condition: Low Back Pain
MeSH terms: Back Pain; Low Back Pain
Study type: Interventional

Summary: 
      The research objective is to determine which physical therapy (PT) treatment is the most
      efficacious for patients with lower back pain (LBP), who have been subgrouped based on
      certain clinical features. There is only limited evidence that supports any one PT treatment
      for patients with LBP since PT treatment outcomes for exercise protocols are equivocal, given
      the heterogeneous clinical features of patients with LBP. Thus, classification of patients
      with LBP into subgroups with shared clinical features has been identified as a research
      priority by several groups in order to prescribe the most efficacious PT treatment for each
      homogeneous subgroup. The investigators hypothesize that particular PT treatments are most
      efficacious when applied to patients with LBP, who present with particular clinical and
      neuromuscular features.
    

Detailed description: 
      The proposed studies focus on 2 schemas to classify LBP: 1) the Treatment-Based
      Classification (TBC) system, from which clinical prediction rules about who is most likely to
      benefit from spinal stabilization exercises (among others) have been developed, and 2) the
      Movement System Impairment-Based Classification (MSI) system, which includes 5
      classifications of LBP named for the specific direction(s) of movements and alignments
      associated with the person's LBP.

      The primary purpose of this proposal is to conduct a prospective, randomized, controlled
      Phase II clinical trial in order to examine whether or not treatment matched to a patient's
      specific signs and symptoms (patient-matched) per the TBC is more effective than the MSI
      system for improving short- (6 weeks) and long-term (12 and 24 months) outcomes in people
      with chronic LBP. A secondary purpose is to identify prognostic factors that predict clinical
      outcomes in the 2 treatment groups being compared.

      Subjects will be assigned to one of two study arms:

        1. eligible for Treatment-Based Classification (TBC) stabilization exercises based on
           current criteria ('Eligible' Subject Group); and

        2. subjects who are not eligible for the TBC-based stabilization exercises ('Ineligible'
           Subject Group).

      Within in each study arm, subjects will be randomly assigned to 1 of 2 exercise protocols for
      a 6-week period:

        1. stabilization - a protocol focused on improving the motor control of trunk muscles to
           stabilize the spine; or

        2. MSI-based - a classification-specific treatment focused on education and instruction for
           modifying movement strategies during functional activities, and on exercises specific to
           the classification category.

      Laboratory measures (muscle activation, kinematics, forces) during standardized tasks will
      quantify neuromuscular impairments associated with LBP and clinical questionnaires will
      quantify changes in pain, function, and health status pre- and post-treatment. The addition
      of neuromuscular measures to these classification schemas could improve the sensitivity and
      specificity of each.
    

Intervention name(s): Physical Therapy rehabilitation: Stabilization exercises.; Physical Therapy rehabilitation. Movement System Impairment (MSI) classification based exercise
Intervention type(s): Other; Other
Intervention description(s): The stabilization exercise protocol consists of exercises focused on improving the ability of trunk muscles to stabilize the spine, beginning with training to isolate the deeper abdominal muscles and then incorporation of these isolated contractions into other exercises. The exercise protocol progresses to include trunk flexion and extension strengthening exercises as well as abdominal bracing exercises in supine and quadruped positions, and finally to exercises in more functional positions.; The MSI-classification based approach focuses on education and instruction for modifying movement strategies during functional activities, and on exercises that are specific to the classification category. First there is an analysis of and instruction in modifying a subject's direction-specific alignment and movement strategies during symptomatic functional activities. Second, there is education about the principles of tissue injury and healing, and how cumulative tissue stress contributes to microtrauma and LBP. Unique to the education process is the emphasis on how using one's particular movement strategies during functional activities may accelerate tissue stress accumulation because the strategies are used repetitively. Thirdly, there is exercise prescription that includes practice in performing modified versions of the direction-specific impairment tests from the physical exam, with an emphasis on impairments that can be modified to eliminate LBP symptoms.
Other intervention name(s): Trunk stabilization exercises; Segmental stabilization exercises; Specific exercise; Sarhmann exercise approach; MSI exercises
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Stabilization exercise; Physical therapy; Rehabilitation; Movement System Impairment exercise