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Motor skill training for back pain slightly better than stretching/strengthening

PainSci » bibliography » van Dillen et al 2021
Tags: back pain, stretch, exercise, pain problems, spine, self-treatment, treatment, muscle

Two articles on PainSci cite van Dillen 2021: 1. Quite a Stretch2. The Complete Guide to Low Back Pain

PainSci commentary on van Dillen 2021: ?This page is one of thousands in the bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

This is a study of quite a complex approach to treating back pain: “motor skill training” (MST) for many weeks, with training “boosters” for people who couldn’t get the hang of it, guided by several professionals who themselves were all quite thoroughly prepped to delivery something like a standardized protocol… yet also individualized! Standardized individualization? What could possibly go wrong?

So what is MST? Basically, “challenging functional activities that were difficult to perform because of LBP.” Even more basically: practicing the movements you’re struggling with because ouch, back pain!

van Dillen et al. compared MST to typical strength and flexibility training, measuring the effect on pain over, using a 100-point disability scoring system (MOSDQ) right after the 8-week program was completed, plus six and twelve months later. (Note that MOSDQ is intended to measure disability in patients with severe back pain, while these study subjects had mild to moderate disability only, for which the Roland-Morris would be better, ahem).

The paper makes it sound like MST won hands down, but the differences seem minor to me, and declined to trivial differences over time; so this is a classic damned with faint praise result. Both groups improved. It is true that the MST group improved more, but not a lot more. Everyone started out with MOSDQ scores around 32, and all the MST brought people down to about 13, while stretching and strengthening only dropped scores to about 21. That might seem like a big difference compared to each other, but the absolute difference is less than 10%. It gets a less impressive when you see that it’s the same as a sub 1-point difference on 10-scale. It’s not nothing, but it’s not nearly large enough to be trusted.

The authors treat slightly beating “stretching and strengthening” as a win here, but … stretching and strengthening aren’t exactly legendary for their powers to solve back pain. Nothing is. How much do you want to brag about just barely winning a foot race against someone with a handicap?

Subjects with no treatment at all would have improved too, because that’s just what back pain does, and so that the comparison that was actually needed here. How much better is MTS than doing nothing?

The problems with this study are piling up. Complexity can hide many science sins, and I fear that several are hidden here — just too many ways to spin the data to make it look like a win.

~ Paul Ingraham

Common issues and characteristics relevant to this paper: ?Scientific papers have many common characteristics, flaws, and limitations, and many of these are rarely or never acknowledged in the paper itself, or even by other reviewers. I have reviewed thousands of papers, and described many of these issues literally hundreds of times. Eventually I got sick of repeating myself, and so now I just refer to a list common characteristics, especially flaws. Not every single one of them applies perfectly to every paper, but if something is listed here, it is relevant in some way. Note that in the case of reviews, the issue may apply to the science being reviewed, and not the review itself.

  1. Damned with faint praise — technically positive results (at least partially) that don’t actually impress.
  2. A high (and possibly unacknowledged) risk of bias and its consequences (p-hacking, etc).
  3. Poorly chosen experimental and/or control groups, not possible to actually answer the question

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

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

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