Research

JAMA Neurology | Original Investigation

Effect of Motor Skill Training in Functional Activities vs Strength

and Flexibility Exercise on Function in People With Chronic Low Back Pain
A Randomized Clinical Trial
Linda R. van Dillen, PhD; Vanessa M. Lanier, DPT; Karen Steger-May, MA; Michael Wallendorf, PhD; Barbara J. Norton, PhD;
Jesse M. Civello, DPT; Sylvia L. Czuppon, DPT; Sara J. Francois, DPT; Kristen Roles, MS; Catherine E. Lang, PhD

Supplemental content
IMPORTANCE 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.

OBJECTIVE 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.

DESIGN, SETTING, AND PARTICIPANTS 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.

INTERVENTIONS 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.

MAIN OUTCOMES AND MEASURES The primary outcome was the modified Oswestry Disability
Questionnaire (MODQ) score (0%-100%) evaluated immediately, 6 months, and 12 months
following treatment.

RESULTS 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.

CONCLUSIONS AND RELEVANCE 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.

TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02027623

Author Affiliations: Author

affiliations are listed at the end of this
article.
Corresponding Author: Linda R.
van Dillen, PhD, Program in Physical
Therapy, Washington University in St
Louis, School of Medicine, 4444
Forest Park Blvd, Campus Box 8502,
JAMA Neurol. 2021;78(4):385-395. doi:10.1001/jamaneurol.2020.4821 St Louis, MO 63108 (vandillenl@
Published online December 28, 2020. Corrected on January 19, 2021. wustl.edu).

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 Research Original Investigation Effect of Motor Skill Training vs Strength and Flexibility Exercise on Function in Chronic Low Back Pain

C
hronic low back pain (LBP) is the most prevalent type of
chronic pain in adults,1 and there is no clearly optimal Key Points
method of management. Exercise is an effective, non-
Question Does person-specific motor skill training in functional
pharmacologic treatment for chronic LBP,2-5 and most clinical activities result in better short-term and long-term outcomes than
practice guidelines recommend exercise as first-line treatment strength and flexibility exercise in people with chronic, nonspecific
for chronic LBP.4,6,7 However, there is limited evidence about low back pain?
(1) which exercise is best5,8-10 and (2) the long-term effects of dif-
Findings In this randomized clinical trial of 149 participants,
ferent exercise-based treatments.2,4 motor skill training reduced disability (modified Oswestry
Difficulty performing daily functional activities is the Disability Questionnaire scores) more than strength and flexibility
primary reason that people with chronic LBP seek health exercise by 7.9 points after treatment, 5.6 points 6 months after
care. 11-13 People with spinal pain, including chronic LBP, treatment, and 5.7 points 12 months after treatment, all clinically
report more pain and limitations in simple movements and important changes from baseline and significant differences
between treatment groups.
complex functional activities than people with other medical
conditions.14 Given the large detrimental effect of LBP on Meaning Person-specific motor skill training in functional
function, a logical form of exercise-based treatment is person- activities limited because of low back pain should be considered to
specific training to improve performance of functional activi- improve limited function in people with chronic low back pain.
ties. The goal of training would be to replace long-standing,
pain-provoking movements and alignments with pain-free
versions. The training should be (1) based on the person’s spe- try Disability Questionnaire (MODQ) score of at least 20%,
cific clinical presentation and limitations and (2) reinforced (5) with at least 3 functional activities limited due to LBP, (6) who
with repeated performance of functional activities across the could stand and walk without assistance, and (7) who could un-
day to facilitate learning. derstand and read English and understand and sign a consent
The potential importance of training people in functional form. People were excluded if they had any structural spinal de-
activities limited because of LBP comes from a trial compar- formity, osteoporosis, ankylosing spondylitis, rheumatoid ar-
ing 2 exercise-based treatments.15 In the trial, both treatment thritis, symptomatic disc herniation, or spondylolisthesis. They
conditions included 2 exercise-based components, (1) tradi- also were excluded if they had a history of spinal fracture, sur-
tional therapeutic exercise (eg, abdominal strengthening) and gery, neurologic disease requiring hospitalization, LBP owing
(2) training to change functional activity performance (eg, to trauma, or unresolved cancer. Other exclusion criteria were
reducing the initial movement of the lumbar spine when body mass index greater than 30 (calculated as weight in kilo-
picking up an object). Both groups demonstrated clinically im- grams divided by height in meters squared); spinal tumor or in-
portant improvement16 in short-term and long-term out- fection, frank neurological loss, pain, or paresthesia below the
comes. However, adherence to functional activity training and knee; active treatment for cancer; LBP etiology other than the
not traditional exercise had a unique, independent effect on lumbar spine; pregnancy; LBP-related worker’s compensa-
outcomes. Such findings suggested that the functional activ- tion, disability, or litigation; or inability to classify the LBP
ity training was key to short-term and long-term improve- condition.
ment. However, one limitation was that all people performed Recruitment was by way of flyers placed in the commu-
both traditional exercise and functional activity training. To nity and physician offices and advertisements and inter-
understand the independent effects of the 2 types of exer- views through local media and clinics in the region. Recruit-
cise, this trial compared the efficacy of a treatment of strength ment spanned December 2013 to August 2016. Final follow-up
and flexibility exercise (SFE), a commonly prescribed treat- outcomes were obtained in November 2017.
ment for chronic LBP, with person-specific training in func-
tional activities. To improve the protocol from the prior study, Design
the training was based on principles that facilitate learning new The study was a 2-treatment group, 1-center, prospective, single
motor skills, hereinafter referred to as motor skill training blind, randomized clinical trial. Testing was conducted in the
(MST). To direct the person-specific aspect of the MST, we clas- Movement Science Research Center at Washington Univer-
sified the person’s LBP condition.17,18 Our primary goal was to sity in St Louis, Missouri. Initially, a standardized examina-
evaluate improvement in LBP-related functional limitation im- tion was performed by a trained assessor to classify the per-
mediately and at 6 and 12 months after treatment. A second- son’s LBP.20-23 Classification was based on the person’s altered
ary goal was to determine whether we could prevent decline lumbar movements and alignments and pain reports during
in outcomes after 6 months with booster treatments. clinical tests and was used to design person-specific treat-
ment in the MST condition. At enrollment, participants were
randomized into 1 of 4 groups (ie, MST with no booster, MST
plus booster, SFE with no booster, or SFE plus booster) with
Methods randomization sequences generated a priori by the study stat-
Participants istician using a formal probability model, a 1:1:1:1 allocation ra-
People included were (1) between age 18 and 60 years, (2) had tio, and a block size of 16. Randomization was stratified by LBP
chronic LBP for at least 12 months, (3) currently experiencing classification (ie, rotation, extension, flexion, rotation with flex-
LBP but not in an acute flare-up,19 (4) with a modified Oswes- ion, or rotation with extension) and elicited from the data cap-

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 Effect of Motor Skill Training vs Strength and Flexibility Exercise on Function in Chronic Low Back Pain Original Investigation Research

ture system. Treatment duration was 6 weeks for 1 hour per tion(s) related to the patient’s LBP classification. Participants
week. At 6 months after treatment, participants randomized were given cues for using trunk muscles needed to facilitate
to treatment plus booster received up to 3 booster treat- the correct movement or alignment during activities. The train-
ments in their initial treatment assignment. The number of ing focused on problem solving by the participant to learn to
booster treatments was based on the participant’s ability to perform the activities without increased LBP.
perform his home program without coaching.24 Data col- Strength and flexibility exercises focused on improving the
lected included self-report and laboratory measures. All strength of all of the trunk muscles and improving trunk and
data were collected at baseline and both immediately and 6 lower limb flexibility in all planes. All exercises were pre-
months after the end of treatment. Additionally, a subset of scribed and progressed based on American College of Sports
self-report data was collected monthly for 12 months via Medicine guidelines. 27 A change in LBP (increase or de-
electronic mail. crease) during exercise was not used to guide prescription or
The trial ended on attainment of 12-month outcomes. In progression. The full trial protocol including a detailed de-
November 2013, trial exclusion criteria were changed to ex- scription of each treatment condition is in Supplement 1 and
clude people with fibromyalgia, Marfan syndrome, and Graves in the eMethods in Supplement 2.
disease. These were excluded to avoid enrolling people with
conditions characterized by diffuse pain owing to a systemic Outcomes
disorder. In October 2015, trial exclusion criteria were changed Outcomes were measured with patient-reported data ob-
to exclude people with a history of disc herniation only if they tained from validated questionnaires. All patient-reported data
had current symptoms below the knee, indicating the hernia- were collected using Research Electronic Data Capture.28,29 The
tion was contributing to the current clinical presentation. The primary outcome was the MODQ (0%-100%), a validated mea-
trial design had no other changes. The study protocol was ap- sure of LBP-related functional limitation where higher scores
proved by the human research protection office at Washing- indicate greater limitation.30 Secondary outcomes included
ton University School of Medicine. Written informed consent (1) the Numeric Pain Rating Scale for average and worst LBP
was obtained from all participants. in prior 7 days31; (2) number, length, and intensity of acute flare-
ups of LBP in prior 6 months19,32; (3) current LBP medication
Interventions use; (4) 36-Item Short Form Health Survey Physical and Men-
Treatment was provided at a university-based outpatient physi- tal Component Summary scores33-35; (5) absenteeism from
cal therapy clinic. Each therapist (n = 8) was given 8 hours of usual activities36; (6) presenteeism related to work impair-
training in 1 of 2 treatment conditions by 2 of the authors (L.V.D. ment, work output, and work absenteeism37,38; (7) care seek-
and C.E.L.). Initially and annually, each therapist was required ing for LBP; (8) equipment use for LBP; (9) adherence15,39; (10)
to pass (score ≥90%) a written and practical examination. The fear-avoidance beliefs40,41; and (11) satisfaction with care.42
SFE therapists were masked to LBP classification. Therapists and Testers were masked to treatment assignment throughout the
participants were not masked to treatment assignment. In both study.
conditions, education and 1 of 2 types of exercise was pro-
vided; MST or SFE. Once educational principles were mas- Power and Statistical Analysis
tered, treatment focused solely on the exercise component. Pro- The power analysis for detecting a minimal clinically impor-
gression was based on the participant’s ability to perform each tant difference of 6 on the MODQ43 based on hierarchical mul-
treatment item independently.24 A home program was pre- tiple regression indicated that 154 participants needed to be
scribed and progressed across the treatment phase. Partici- enrolled for 80% power, assuming 20% attrition, α = .05, and
pants were instructed to receive no other treatments for LBP dur- 2-tailed tests. The original protocol called for analysis with hi-
ing the treatment phase. At the final clinic visit, participants were erarchical linear modeling to model repeated measures with-
instructed to continue the home program. out requiring time between samples to be constant. How-
Motor skill training involved supervised, massed prac- ever, the times between samples were sufficiently consistent
tice of challenging functional activities that were difficult to to allow mixed-effects repeated-measures analysis.
perform because of LBP.25,26 Participants assisted in choos- For MODQ, mixed random-effects repeated-measures
ing activities. Difficulty was graded continuously within and analyses were conducted separately on each phase (treat-
across visits to match motor capabilities. Extrinsic feedback ment and follow-up), with participant within treatment as a
was minimized during practice and removed as quickly as pos- random effect and a first-order autoregressive covariance struc-
sible. Practice was based on the (1) participant’s ability to per- ture to account for correlation between points. The baseline
form the activity and (2) level of challenge the participant MODQ score was used as a covariate to control for baseline par-
was faced with daily. Emphasis was on changing the altered ticipant differences. Treatment, time, and time by treatment
movements and alignments relevant to the person-specific interaction were included in the model as fixed effects. Booster
classification17,18 during activities to reduce LBP. The pri- treatments after follow-up month 6 did not affect subse-
mary treatment principles were to teach the participant to quent MODQ scores (eTable in Supplement 2); treatment es-
(1) move the lumbar spine later and reduce the amount of lum- timates from data after month 6 were created from combined
bar spine movement(s) related to their LBP classification (eg, booster and no booster groups within treatment. The analy-
flexion), (2) increase use of other joints (eg, hips), and (3) avoid ses were intention to treat where all randomized participants
end-range positioning of the lumbar spine in specific direc- who started the allocated intervention were included. Some

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 Research Original Investigation Effect of Motor Skill Training vs Strength and Flexibility Exercise on Function in Chronic Low Back Pain

Figure 1. Enrollment, Randomization, Treatment, and Follow-up

1595 Participants screened for eligibility

1441 Excluded
1235 During screening
1232 Did not meet eligibility criteria
3 Could not be contacted
66 During first visit
63 Did not meet eligibility criteria
3 Were no longer interested
140 Had no first visit scheduled
38 Could not be contacted
34 Did not schedule visit until after enrollment capacity was met
31 Had a medical or referral issue
27 Were no longer interested
7 Were no longer qualified
3 Had scheduling issues

154 Randomized at first visit

37 Assigned to MST alone 40 Assigned to MST with booster 41 Assigned to SFE alone 36 Assigned to SFE with booster
35 Received partial or all of treatment 40 Received partial or all of treatment
assigned treatment 39 Received partial or all of assigned treatment 35 Received partial or all of
2 Discontinued trial participation assigned treatment 1 Discontinued trial participation assigned treatment
1 No longer interested 1 Discontinued trial participation because of scheduling issues 1 Discontinued trial participation
1 Could not be contacted because they were no longer because of insufficient time
interested

33 Attended second visit 35 Attended second visit 35 Attended second visit 32 Attended second visit
2 Discontinued trial participation 4 Discontinued trial participation 5 Discontinued trial participation 3 Discontinued trial participation
1 Had insufficient time 2 Could not be contacted 2 Could not be contacted 2 Had insufficient time
1 Lacked transportation 1 Had insufficient time 2 Had insufficient time 1 Relocated
1 Had back pain improve 1 Relocated

31 Attended third visit 34 Attended third visit 30 Attended third visit 30 Attended third visit
2 Refused third visit but continued 1 Refused third visit but continued 4 Refused third visit but continued 1 Refused third visit but continued
trial participation trial participation trial participation trial participation
1 Discontinued trial participation 1 Discontinued trial participation
because of an unrelated because they could not be
illness/injury contacted

34 Informed of booster assignment 30 Informed of booster assignment

after third visit after third visit
33 Received booster 24 Received booster
1 Refused booster but continued 6 Refused booster but continued
trial participation trial participation

35 Included in the intention-to-treat 39 Included in the intention-to-treat 40 Included in the intention-to-treat 35 Included in the intention-to-treat
analysis analysis analysis analysis

Participant randomization was determined at laboratory visit 1 after the or SFE with booster (SFE+B). Participants were informed of their assigned
participant completed the clinical examination. Each participant enrolled was treatment condition (MST or SFE) after laboratory visit 1 (baseline visit) and of
randomized to 1 of 4 groups: motor skill training without booster (MST-B), MST their booster randomization after laboratory visit 3 (6-month follow-up visit).
with booster (MST+B), strength and flexibility exercise without booster (SFE-B),

data were missing at random; however, 68 MST and 67 SFE par-

ticipants provided at least 6 of 7 MODQ scores during the treat- Results
ment phase. No missing data imputation was performed.44
Mean estimates for single points were model-based least square Participants
(LS) means (unless otherwise noted). The standardized mean One hundred fifty-four participants were enrolled (Figure 1).
difference also was calculated for the treatment and fol- Fourteen percent of participants (21 of 154) withdrew across
low-up phase. the study period. Five withdrawals were prior to treatment

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 Effect of Motor Skill Training vs Strength and Flexibility Exercise on Function in Chronic Low Back Pain Original Investigation Research

Table 1. Characteristics for Enrolled Participants Who Started Treatment

No. (%)
Treatment group
Complete sample Motor skill training Strength and flexibility
Characteristic (N = 149) (n = 74) exercise (n = 75) P valuea
Demographic variables
Femaleb 91 (61) 50 (68) 41 (55) .11
Age, mean (SD), y 42.5 (11.7) 42.4 (11.8) 42.6 (11.7) .90
White race/ethnicityc 115 (77) 58 (78) 57 (76) .73
BMI, mean (SD) 25.7 (3.2) 25.3 (3.2) 26.1 (3.1) .16
Married or living with 100 (67) 45 (61) 55 (73) .10
significant other Abbreviations: BMI, body mass index
Completed at least some 139 (93) 67 (91) 72 (96) .21d (calculated as weight in kilograms
college divided by height in meters squared);
Employment situationc IQR, interquartile range; LBP, low
back pain.
Working full time 101 (68) 50 (68) 51 (68) a
Unless otherwise noted, P value
Working part time 28 (19) 15 (20) 13 (17) compares treatment groups by
.32d
Student (not working) 5 (3) 4 (5) 1 (1) unpaired t test (for continuous
Other employment status 15 (10) 5 (7) 10 (13) variables) or χ2 test (for categorical
variables).
LBP-related variables b
Participant-reported gender
LBP classification identity.
Rotation 82 (55) 42 (57) 40 (53) c
Data captured by participant report
Rotation with flexion 4 (3) 1 (1) 3 (4) .71d with several “check all that apply”
categories. White race/ethnicity
Rotation with extension 63 (42) 31 (42) 32 (43)
includes a multiracial identification
Duration of LBP, median 7.0 (12.0) 7.0 (17.0) 7.0 (11.0) .98d that includes white. Race/ethnicity
(IQR), y category options are those required
Symptoms only in backe 112 (76) 58 (79) 54 (72) .29 for reporting to the funding agency.
Medication usef Employment includes
multiemployment identification,
Taking nonprescription 90 (60) 46 (31) 43 (29) .63
medication where a single category is assigned
in the listed order of priority.
Taking prescription 28 (19) 13 (46) 15 (54) >.99
d
medication P value compares treatment groups
Nonsteroidal 8 (5) 3 (4) 5 (7) .70d by Wilcoxon test (for nonnormal
anti-inflammatory continuous variables) or Fisher
Opioid or opiate pain 4 (3) 1 (1) 3 (4) .60d exact test (for categorical variables
reliever with small cell sizes).
e
Prescription 22 (15) 11 (15) 11 (15) >.99d Data missing for 1 MST participant.
acetaminophen Operational definition for location
Skeletal muscle relaxant 11 (7) 4 (5) 7 (9) .50d “only in back” is symptoms in region
from T12 to gluteal fold.
Antidepressants 1 (0.7) 1 (1) 0 .50d
f
Participants could be taking more
Glucocorticoids 1 (0.7) 0 1 (1) >.99d
than 1 medication.

(3 in the MST arm and 2 in the SFE arm; LBP classification: 4 ment was large (SMD, 0.85; 95% CI, 0.51-1.19) and after 12
rotation and 1 rotation with extension; 4 women and 1 man) and months was moderate (0.56; 95% CI, 0.22-0.90).45
were not included in the data analyses. Sixteen withdrawals
were during or after treatment (MST = 6 and SFE = 10). Base- Secondary Efficacy End Points
line characteristics of participants were not significantly differ- Many of the secondary outcomes also showed statistically sig-
ent between the 2 treatment groups (Table 1). nificant differences in favor of MST vs SFE (Table 3). Posttreat-
ment MST resulted in higher satisfaction with care, greater
Outcomes improvement in average and worst LBP and physical func-
Primary Efficacy End Point: MODQ tion, less LBP-related medication use, less absenteeism from
During the treatment phase, MST reduced MODQ scores30 more usual activities, and lower work-related fear avoidance be-
than SFE. At the posttreatment stage, MST was lower than SFE liefs compared with SFE. Six months after treatment, MST also
by 7.9 (95% CI, 4.7-11.0; P < .001) (Figure 2A, Table 2). During resulted in fewer and shorter acute LBP flare-ups and greater
the follow-up phase, the MST group maintained lower levels adherence compared with SFE. Finally, at 12 months, MST
of MODQ scores than the SFE group, 5.6 lower at 6 months (95% yielded lower average and worst LBP than SFE. However, ben-
CI, 2.1-9.1) and 5.7 lower at 12 months (95% CI, 2.2-9.1) efits of MST vs SFE did not occur at any point for intensity of
(Figure 2B). Booster sessions after follow-up month 6 did not acute flare-ups, mental function, work impairment and work
change MODQ scores in either treatment (eTable in Supple- absenteeism, physical function–related fear avoidance be-
ment 2). The standardized mean difference (SMD) after treat- liefs, equipment use, or care seeking for LBP.

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 Research Original Investigation Effect of Motor Skill Training vs Strength and Flexibility Exercise on Function in Chronic Low Back Pain

Figure 2. Modified Oswestry Disability Questionnaire Scores (MODQ) Table 2. Modified Oswestry Disability Questionnaire Score Differences
Over Time at Baseline, Posttreatment, Follow-up Month 6, and Follow-up Month 12a

Means (SD)b
A Treatment phase Treatment Strength and Mean
35 MST Motor skill flexibility difference
SFE (95% CI)c
Least-square mean MODQ score

Time training exercise P value

30
Baseline 32.3 (10.2) 32.6 (9.4) NA NA
25 Posttreatment 12.8 (10.7) 21.2 (10.7) 7.9 (4.7-11.0) <.001
20 Follow-up
15 Month 6 12.0 (12.6) 18.2 (10.5) 5.6 (2.1-9.1) .002
Month 12 10.8 (11.3) 16.7 (11.3) 5.7 (2.2-9.1) .001
10
Abbreviation: NA, not applicable.
5
a
Scores on the modified Oswestry Disability Questionnaire range from 0% to
0 100%; 100% represents the highest level of limitation.
Baseline 1 2 3 4 5 6 Posttreatment
b
Treatment week Sample means and standard deviations.
c
Model-based contrasts.
B 12-mo Follow-up
35
Least-square mean MODQ score

30
Discussion
25

20 Our study provides evidence that person-specific MST in LBP-

15 limited functional activities results in greater short-term and
long-term improvements in function than traditional strength
10
and flexibility exercise (SFE). Immediately after treatment, both
5
the MST and SFE groups displayed clinically meaningful
0 improvement16,43 in function. However, MST demonstrated al-
1 2 3 4 5 6 7 8 9 10 11 12
Follow-up, mo most twice the improvement in function (60% change) as SFE
(35%). Most importantly, the between-group differences in
A, Least-square mean MODQ scores (with 95% confidence interval bars) over MODQ scores were sustained at the 6-month and 12-month fol-
time during the treatment phase for the motor skill training (MST) group and low-up. These findings are highly relevant given the primary rea-
the strength and flexibility exercise (SFE) group. Scores on the MODQ range
from 0% to 100%; 100% represents the highest limitation. The MST group
son people with chronic LBP seek health care is difficulty per-
improved to a greater degree than the SFE group. B, Least-square mean MODQ forming functional activities.11-13 The effects also were obtained
scores (with 95% confidence interval bars) over time in the 12 month follow-up with only 6 one-hour treatments. In addition, self-reported
phase for the 2 treatment conditions. Both groups maintained improvements
adherence to MST was consistently high, suggesting MST pro-
obtained with treatment. The mean MODQ score over the 12 month follow-up
phase for the MST group was lower than for the SFE group. vides a feasible means for self-management (Table 3).
The findings across the secondary outcomes display a pat-
tern that also supports MST as more effective than SFE, al-
Adverse Events though the mean differences tend to be small or the range of
Treatment Phase the confidence intervals are large (Table 3). Five of the 6 pain-
No serious adverse events were reported. Nonserious ad- related variables (average and worst pain, acute flare-up num-
verse events included reports of a worsening of LBP (opera- ber and length, and medication use) favored MST to SFE at early
tional definition in the protocol) by 62 participants (107 oc- and late points. Three of the 6 physical function-related vari-
currences); 2 SFE participants and 1 MST participant (4 ables (36-Item Short Form Health Survey physical function,
occurrences; 4%) related the increase to treatment. All re- work output, and absenteeism from usual activities) and work-
ports were resolved by the next treatment visit. related fear avoidance improved to a greater degree for MST
than SFE at the earliest point. In addition, people were more
Follow-up Phase satisfied and tended to adhere more to MST than SFE.
No serious adverse events were related to treatment. Two Our results suggest that the use of principles of motor
serious adverse events unrelated to treatment were reported. learning25,46-48 to drive change in function is critical for people
One participant was diagnosed as having ductal carcinoma. A with chronic LBP. Instead of assuming that the benefits of tra-
second participant had minimally invasive surgery for disc ditional exercise generalize to functional activities, we pro-
herniation. There were no nonserious adverse events related vided person-specific MST directly targeting how people
to treatment. Nonserious adverse events unrelated to treat- performed functional activities. Specifically, challenging be-
ment included 5 reports of lower extremity injury or pain, 1 havioral demands were repeatedly imposed to facilitate learn-
increase in LBP as an adverse effect of medication use, 1 ing to change LBP-provoking strategies used across multiple
unexplained increase in LBP for 1 month, 2 reports of influ- activities. The goal was to change long-standing strategies to
enza, 1 diagnosis of osteoporosis, 1 diagnosis of facial palsy, improve the short-term and long-term course of the condi-
and 1 pregnancy. tion. Indeed, our results showed that the MST group dis played

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 Effect of Motor Skill Training vs Strength and Flexibility Exercise on Function in Chronic Low Back Pain Original Investigation Research

Table 3. Secondary Outcome Treatment Least Square Mean Differences and Odds Ratios at Posttreatment, Follow-up Month 6,
and Follow-up Month 12

Sample means (SD)

Motor skill training Strength and flexibility LS mean difference: SFE − MST
Variable Single time points (n = 74) exercise (n = 75) (95% CI)
Numeric Pain Rating Scalea
Baseline 4.7 (1.9) 4.7 (1.5) NA
Posttreatment 1.4 (1.1) 2.1 (1.2) 0.8 (0.3 to 1.2)
Average
Follow-up mo 6 2.0 (1.8) 2.6 (1.8) 0.5 (−0.1 to 1.1)
Follow-up mo 12 1.8 (1.9) 2.6 (2.0) 0.8 (0.2 to 1.4)
Baseline 6.3 (2.0) 6.9 (1.6) NA
Posttreatment 2.7 (1.7) 4.0 (1.9) 1.0 (0.4 to 1.7)
Worst
Follow-up mo 6 2.9 (2.2) 3.8 (2.2) 0.6 (−0.2 to 1.3)
Follow-up mo 12 2.8 (2.3) 3.9 (2.5) 1.0 (0.2 to 1.7)
Acute flare-ups of LBP
in prior 6 mosb
Baseline 7.1 (7.6) 9.8 (11.9) NA
No. Follow-up mo 6 2.0 (3.3) 4.2 (8.2) 0.8 (0.1 to 1.5)
Follow-up mo 12 1.3 (1.8) 2.0 (2.8) 0.3 (−0.2 to 0.9)
Baseline 4.4 (5.4) 3.7 (6.9) NA
Length Follow-up mo 6 1.7 (2.1) 3.9 (7.0) 0.9 (0.2 to 1.8)
Follow-up mo 12 2.0 (4.0) 2.8 (7.6) 0.3 (−0.3 to 1.0)
Baseline 6.6 (2.5) 6.1 (2.6) NA
Intensity Follow-up mo 6 3.1 (3.2) 3.9 (2.9) 0.7 (−0.3 to 1.8)
Follow-up month 12 2.6 (3.0) 3.4 (3.2) 0.7 (−0.4 to 1.8)
SF-36 Component Summary
Scoresc
Baseline 43.2 (6.6) 40.8 (6.9) NA
Posttreatment 50.8 (6.5) 46.3 (7.0) −2.9 (−5.0 to −0.9)
Physical
Follow-up mo 6 50.9 (6.6) 47.8 (7.4) −1.8 (−4.3 to 0.7)
Follow-up mo 12 51.2 (8.0) 48.3 (7.4) −2.0 (−4.5 to 0.4)
Baseline 49.2 (11.6) 52.1 (9.3) NA
Posttreatment 50.7 (8.6) 51.0 (11.6) −1.3 (−4.2 to 1.6)
Mental
Follow-up mo 6 49.6 (10.5) 50.8 (10.4) 0.1 (−3.2 to 3.5)
Follow-up mo 12 50.4 (10.3) 50.3 (11.5) −1.3 (−4.6 to 2.0)
Stanford Presenteeism Scaled
Baseline 20.3 (5.3) 19.9 (6.2) NA
Posttreatment 17.4 (4.6) 18.3 (5.2) 1.3 (−0.3 to 2.8)
Work Impairment Score
Follow-up mo 6 15.9 (5.6) 16.5 (5.3) 1.4 (−0.4 to 3.2)
Follow-up mo 12 15.4 (5.1) 16.7 (6.0) 1.6 (−0.2 to 3.4)
Baseline 87.0 (15.3) 83.4 (19.3) NA
Posttreatment 95.4 (7.4) 91.6 (11.4) −1.9 (−3.6 to −0.5)
Work Output Score
Follow-up mo 6 95.2 (9.0) 93.1 (16.9) −0.2 (−1.5 to 1.0)
Follow-up mo 12 95.7 (8.6) 96.2 (6.2) 0.3 (−0.8 to 1.3)
Posttreatment 83 (14) 90 (15) 6.7 (2.8 to 12.0)
Adherence to home programe Follow-up mo 6 70 (21) 42 (31) −40.8 (−52.9 to −27.9)
Follow-up mo 12f 70 (21) 51 (35) −19.1 (−37.9 to 0.4)
Fear-Avoidance Beliefs
Questionnaireg
Baseline 14.7 (6.1) 14.1 (5.1) NA
Physical score Posttreatment 11.4 (5.9) 11.6 (5.3) 0.4 (−1.4 to 2.2)
Follow-up mo 6 11.0 (5.8) 11.4 (5.5) 0.7 (−1.2 to 2.5)
Baseline 10.9 (8.4) 11.8 (9.0) NA
Work score Posttreatment 7.7 (7.1) 10.9 (9.5) 2.3 (0.01 to 4.6)
Follow-up mo 6 7.2 (8.2) 9.0 (8.7) 0.9 (−1.5 to 3.3)

(continued)

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 Research Original Investigation Effect of Motor Skill Training vs Strength and Flexibility Exercise on Function in Chronic Low Back Pain

Table 3. Secondary Outcome Treatment Least Square Mean Differences and Odds Ratios at Posttreatment, Follow-up Month 6,
and Follow-up Month 12 (continued)

Sample means (SD)

Motor skill training Strength and flexibility LS mean difference: SFE − MST
Variable Single time points (n = 74) exercise (n = 75) (95% CI)
Satisfaction with careh
Total Posttreatment 68.8 (0.9) 61.4 (0.9) −7.4 (−9.8 to −4.9)
Dichotomous variables
Baseline 50 (68) 47 (63) NA

Current LBP medication use, Posttreatment 21 (30) 31 (46) Odds ratioj, 2.4 (1.1 to 5.4)
No. (%)i Follow-up mo 6 27 (40) 29 (47) Odds ratioj, 1.3 (0.6 to 2.9)
Follow-up mo 12 23 (34) 25 (38) Odds ratioj, 1.4 (0.6 to 3.1)
Baseline 42 (57) 47 (63) NA
Absenteeism from usual Posttreatment 11 (16) 29 (43) Odds ratioj, 4.2 (1.8 to 10.0)
activities,
No. (%)i Follow-up mo 6 9 (14) 11 (18) Odds ratioj, 1.4 (0.5 to 3.4)
Follow-up mo 12 11 (16) 12 (18) Odds ratioj, 1.1 (0.5 to 2.7)
i
Stanford Presenteeism Scale
Baseline 19 (29) 22 (35) NA
Posttreatment 3 (5) 6 (10) Odds ratioj, 3.7 (0.6 to 21.3)
Work absenteeism, No. (%)i
Follow-up month 6 3 (6) 6 (11) Odds ratioj, 1.4 (0.6 to 3.5)
Follow-up month 12 4 (7) 3 (6) Odds ratioj, 1.2 (0.4 to 3.4)
Baseline 35 (47) 29 (39) NA

Health professional care Posttreatment 7 (10) 6 (9) Odds ratioj, 1.0 (0.3 to 3.3)
seeking for LBP, No. (%)i Follow-up mo 6 13 (19) 13 (21) Odds ratioj, 1.1 (0.5 to 2.5)
Follow-up mo 12 8 (12) 11 (17) Odds ratioj, 1.5 (0.5 to 4.0)
Baseline 66 (89) 65 (87) NA

Equipment use for LBP, Posttreatment 62 (91) 48 (71) Odds ratioj, 0.21 (0.07 to 0.58)
No. (%)i Follow-up mo 6 33 (49) 29 (47) Odds ratioj, 0.5 (0.2 to 1.1)
Follow-up mo 12 28 (41) 30 (46) Odds ratioj, 1.1 (0.5 to 2.2)
e
Abbreviations: LBP, low back pain; LS, least square; MST, motor skill training; Adherence to home program ranges from 0% to 100%, with higher values
NA, not applicable; NRS, Numeric Pain Rating Scale; SFE, strength and flexibility indicating higher adherence to treatment. Participants reported weekly
exercise. adherence during the treatment phase and monthly adherence during the
a
Numeric Pain Rating Scale ranges from 0 to 10, with higher scores indicating follow-up phase.
f
more pain. Estimates were based on data from nonbooster treatment groups because
b
A flare-up is an increase in symptoms of at least 2 points on the NRS greater booster sessions affected SFE adherence after follow-up month 6. The SFE
than a participant’s typical low back pain that lasts for at least 2 consecutive adherence increased after booster sessions.
g
days. Participants provided the number in the past 6 months, the length Fear-Avoidance Beliefs Questionnaire physical activity subscale score ranges
(days), and the average pain intensity (NRS) during the flare-ups. from 0 to 24 and work subscale score ranges from 0 to 42 with higher scores
c
36-Item Short Form Health Survey Physical and Mental Component Summary indicating higher fear avoidance.
h
Scores are scaled and normalized to have a mean of 50 and standard deviation Satisfaction with care ranges from 15 to 75 with higher scores indicating more
of 10 in the normal 1998 US population. satisfaction.
d i
Stanford Presenteeism Scale Work Impairment Score ranges from 10 to 50, Sample counts.
with 50 indicating the highest degree of impairment. The Work Output Score j
Model-based odds ratio; SFE odds/MST odds.
is the participant’s estimate of the percentage of his usual productivity level
during work over the past 4 weeks (0%-100%).

greater and more durable improvements in function than the person-specific treatment targeting altered movements and
SFE group. This is a major outcome because a key recommen- alignments (as in the current study) with other treatments. The
dation of clinical practice guidelines for LBP is to use treat- authors concluded that person-specific treatment results in
ments that increase function and discourage behaviors that greater improvement in function than other treatments in the
contribute to persistent disability.6,10 short term and long term, but the effect sizes were small. Ad-
Treatment guidelines for chronic, nonspecific LBP recom- ditionally, the conclusions were tentative because of multiple
mend exercise-based treatments as first-line care.4,6,7,10 How- study limitations. In our high-quality trial, person-specific MST
ever, there is no strong evidence for any specific type of exercise- targeting LBP-limited functional activities resulted in greater im-
based treatment.6,7,10 Some have suggested that classifying a provements in function than SFE in the short term and long term
person’s LBP based on relevant characteristics and providing with large and moderate effect sizes.
person-specific treatment based on that classification could Training in functional activities has been examined as an
improve outcomes.49-51 A 2018 systematic review52 compared exercise-based treatment in prior clinical trials for chronic, non-

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 Effect of Motor Skill Training vs Strength and Flexibility Exercise on Function in Chronic Low Back Pain Original Investigation Research

specific LBP.53-57 A common feature across prior trials was that trained in standardized procedures; knowledge and perfor-
the training was provided in combination with other treat- mance of therapists was examined regularly24; standardized pro-
ment components, making it impossible to determine the spe- cedures for progression of treatment were used24; and medi-
cific effect of training in functional activities. Given the MST cal records were audited for treatment fidelity regularly by
condition only included training in functional activities, our masked assessors.
findings signal the importance of directly addressing person-
specific strategies used during functional activities with MST Limitations
to attain large and long-lasting improvement in function. Ad- A limitation of our study is that our findings may not be
ditionally, because therapists could identify activities and scale generalizable to people with anatomically specific LBP con-
the level of training for participants presenting with varying ditions, substantial behavioral or psychological comorbidi-
levels of limitations, the findings also support the use of MST ties, symptoms below the knee, or high levels of pain and
in functional activities from the outset of treatment. functional limitation. In addition, we cannot know how well
A secondary goal of this study was to test the efficacy of people who have lower levels of education or employment
booster treatments to prevent the decline in function ob- than our participants would perform or whether similar out-
served from 6 to 12 months in the prior clinical trial.15 On aver- comes would be attained if therapists did not have the spe-
age, in the MST condition, there was no effect of booster ses- cific training, testing, monitoring, and feedback provided in
sions on outcomes. The lack of booster effects likely is because our study. Finally, we did not include an attention control
both MST groups (booster and no booster) maintained the gains group.
obtained during the treatment phase and did not decline in the
6 to 12 months after treatment as in the previous trial.15 The lack
of decline is attributed to improvements in the MST design made
based on the prior clinical trial15 experience. It is notable that
Conclusions
the amount of improvement in function initially attained with People with chronic LBP who received person-specific MST
6 weekly treatments (60%) and then maintained over 6 months to change functional activity performance displayed greater
(63%) in MST was similar to gains at the 6-month point (65%) short-term and long-term improvements in function than
in the prior trial. These large improvements also were achieved those who received SFE. A number of pain, physical func-
in a sample of people who were not experiencing an acute tion, and psychological outcomes also improved to a greater
flare-up and had higher levels of functional limitation and LBP degree in the MST group compared with the SFE group.
than in the prior trial.15 In the SFE condition, boosters only af- These findings suggest that a priority of treatment for people
fected adherence; other outcomes did not differ. Specifically, with chronic LBP is to provide person-specific, challenging
adherence was maintained in the booster group but decreased practice that promotes learning new strategies of movement
in the no-booster group (eTable in Supplement 2), suggesting and alignment during LBP-limited functional activities. Use
boosters may be important for reminding people what they of MST appeared to (1) result in improved short-term but
should be doing. more importantly long-term outcomes with only 6 one-hour
Strengths of the study include the randomized, controlled treatments, (2) promote better adherence to training for a
trial design, inclusion of moderately involved people who were prolonged period, and (3) enable a person to practice the
not experiencing an acute LBP flare-up, use of person-specific activities across the day, thus providing a means of self-
treatment, inclusion of 2 active exercise-based treatments, track- management. Such benefits could be key in a condition typi-
ing of adherence, minimal loss to follow-up across the study pe- cally characterized by a clinical course of recurrent, fluctuat-
riod, and an intention-to-treat analysis. Therapists also were ing, or persistent functional limitation and pain.

ARTICLE INFORMATION Washington University School of Medicine in Administrative, technical, or material support:
Accepted for Publication: October 28, 2020. St Louis, St Louis, Missouri (Norton, Lang); Program van Dillen, Lanier, Czuppon, Francois.
in Occupational Therapy, Washington University Supervision: van Dillen.
Published Online: December 28, 2020. School of Medicine in St Louis, St Louis, Missouri
doi:10.1001/jamaneurol.2020.4821 Conflict of Interest Disclosures: Drs van Dillen and
(Lang). Lang and Ms Steger-May reported grant funding
Open Access: This is an open access article Author Contributions: Drs van Dillen and from the National Institutes of Health during
distributed under the terms of the CC-BY License. Wallendorf had full access to all of the data in the conduct of the study. Dr Lang reports personal fees
© 2020 van Dillen LR et al. JAMA Neurology. study and take responsibility for the integrity of the from AOTA Press Inc outside the submitted work.
Correction: This article was corrected on January data and the accuracy of the data analysis. No other disclosures were reported.
19, 2020, to fix errors in Figure 1 and Table 3. Concept and design: van Dillen, Lanier, Norton, Funding/Support: National Institute for Child
Author Affiliations: Program in Physical Therapy, Czuppon, Lang. Health and Human Development, National Center
Washington University School of Medicine in Acquisition, analysis, or interpretation of data: for Medical Rehabilitation Research (grant R01
St Louis, St Louis, Missouri (van Dillen, Lanier, van Dillen, Lanier, Steger-May, Wallendorf, Civello, HD-047709).
Norton, Civello, Czuppon, Francois, Roles, Lang); Francois, Roles, Lang.
Drafting of the manuscript: van Dillen, Lanier, Role of the Funder/Sponsor: The funding sources
Department of Orthopaedic Surgery, Washington had no role in the design and conduct of the study;
University School of Medicine in St Louis, St Louis, Wallendorf.
Critical revision of the manuscript for important collection, management, analysis, and
Missouri (van Dillen, Lanier, Czuppon); Division of interpretation of the data; preparation, review, or
Biostatistics, Washington University School of intellectual content: All authors.
Statistical analysis: Steger-May, Wallendorf. approval of the manuscript; and decision to submit
Medicine in St Louis, St Louis, Missouri (Steger-May, the manuscript for publication.
Wallendorf); Department of Neurology, Obtained funding: van Dillen.

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 Research Original Investigation Effect of Motor Skill Training vs Strength and Flexibility Exercise on Function in Chronic Low Back Pain

Data Sharing Statement: See Supplement 3. 10. Malfliet A, Ickmans K, Huysmans E, et al. Best 24. Harris-Hayes M, Holtzman GW, Earley JA, Van
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(Program in Physical Therapy, Washington back pain. J Clin Med. 2019;8(7):E1063. doi:10. testing of an assessment of patient independence
University School of Medicine, St Louis, Missouri, 3390/jcm8071063 in performing a treatment program: standardized
United States), for assistance with participant 11. Mortimer M, Ahlberg G; MUSIC-Norrtälje Study scenarios. J Rehabil Med. 2010;42(3):221-227.
recruitment and data collection. We also thank Sara Group. To seek or not to seek? care-seeking doi:10.2340/16501977-0505
Putnam, MS (Division of Biostatistics, University of behaviour among people with low-back pain. Scand 25. Lang CE, Birkenmeier RL. Upper-Extremity
Minnesota, Minneapolis, United States), for J Public Health. 2003;31(3):194-203. doi:10.1080/ Task-Specific Training After Stroke or Disability:
participant recruitment, data collection, and 14034940210134086 A Manual for Occupational Therapy and Physical
processing. We thank Greg Holtzman, DPT 12. Ferreira ML, Machado G, Latimer J, Maher C, Therapy. Bethesda, MD: AOTA Press; 2013.
(Program in Physical Therapy, Washington Ferreira PH, Smeets RJ. Factors defining 26. Lanier VM, Lang CE, Van Dillen LR. Motor skill
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Weaver, DPT (ATI Physical Therapy, St Louis, 13. McPhillips-Tangum CA, Cherkin DC, Rhodes LA, 27. Franklin BA, Whaley MH, Howley ET, et al
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