Justification and decreasing levels of disability. Since

Justification of using MCE for LBP
with referred symptoms

A randomised
control trial (RCT) carried out by Macedo et al. (2012) looked at outcome measures
including pain, function, disability and quality of life. All of these outcome
measures were set at 0, 2, 6 and 12 months. The conclusion of this RCT was that
MCE have beneficial effects on reducing pain, increasing function, increasing
quality of life and decreasing levels of disability.

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Since Tim
has non-specific chronic lower back pain both RCT’s mentioned above give
positive results towards using MCE and increasing Tim’s core strength, namely
an increase in muscle strength of Transverse Abdominal muscles in order to
alleviate Tim’s pain and increase his functional ability.

National
Institute for Health and Care Excellence (NICE) (2016) recommend that
non-invasive treatment for lower back pain and sciatica include biomechanical
exercise, including MCE.  

 

Critical Appraisal of Motor Control
Exercises as a treatment for chronic Low Back Pain

In a RCT led
by Costa et al. (2009) we can critically appraise the following:

Validity – RCT
looks at a demographic which includes Tim, outcome measures assessed are
relevant to Tim. Treatment procedure is MCE.

Although it
would be more beneficial to have a higher percentage of participants within a
closer age range to Tim there are limited studies with these parameters. The
RCT clearly assesses the impact of MCE against a placebo treatment. This
further focuses the RCT on the exact benefits of MCE when compared to a
non-optimal treatment for chronic lower back pain.

Reliability –
The assignment of patients to treatments was randomised by a computer generated
sequence by an investigator that was not involved in recruitment of patients.
Allocations were concealed in opaque envelopes.

Groups had
similar demographics and similar outcome scores at the start of the trial. They
were also treated equally in the fact that they had 12 treatments over an 8
week period.

Very close
to 90%+ attended follow ups at 2, 6 and 12 months. So at its conclusion all 154
participants were analysed.  

Conflicts of
interest – Funding from a local university that did not have input into decisions
made during the trial or whether to publish the results.

Responsiveness
– Training of senior physiotherapists was 1 day + 3 half day follow ups +
randomised auditing from the experts in MCE to assess continuity of treatment
throughout trial. This shows a thorough attempt at adapting to improve the
quality of the RCT whilst maintaining credibility during the treatment phase.
Whilst it may have been more beneficial to the RCT to have employed experts in
the MCE field, the cost effective nature may have been too high to outweigh the
benefits.  

Statistical
analysis – Intention-to-Treat (ITT) was implemented and Young and Soloman
(2009) suggest it is preferred as it maintains randomisation throughout the RCT
and ensures both sets of results are comparable at baseline. Confidence limits
are at 95% and Consolidated standards of reporting trials statement flowchart
was adhered to.

 

 

 

 

Another RCT
led by Akbari et al. (2008) can be critically appraised to show the following:

Validity –
RCT assesses a demographic that would include Tim, however in closer detail Tim
would be in the 3rd standard deviation for his age in this RCT. This
needs to be taken into account when assessing how beneficial the results might
be for Tim specifically.

This RCT addresses
a focused issue of whether MCE or general exercise has a beneficial effect on
lumbar stabilising muscle thickness. The outcome measures assessed are all
beneficial for aiding Tim’s continuation with work.

Reliability –
The assignment of participants was carried out by the physiotherapists
generated random number sequence. This could have been improved by a computer
generated random number sequence that was concealed in opaque envelopes. The
physiotherapists involved in treatments were not masked to which treatment they
were giving, but the researchers and radiologists were blind to which groups
they were interpreting.

The groups
had a similar demographic at baseline and the same outcome measures were
assessed in both groups. They were treated equally by having 16 individual
sessions over 8 weeks.

49
participants were analysed at the end of the study. 9 dropped out, reasons were
explained.

The funding
of the study is not included and although this RCT has been approved by the
University Ethics committee and all participants have given informed consent,
it would have been beneficial for excluding any bias if the source of funding
was also included.

No specific
training regarding MCE was given to the physiotherapists, however clear
instructions on what the treatment aims were and how they were carried out was
given. It would increase the responsiveness of the RCT to explicitly state that
the physiotherapists in charge of treatment were adept in carrying out both MCE
and general exercise therapies.

 

Conclusion

Akbari et al
(2008) concludes that MCE is beneficial in reducing pain both short and long
term as well as increasing lumbar stability.

Macedo et al
(2012) concludes that there is no benefit to using MCE over graded activity but
both are beneficial in decreasing pain and increasing function.

Although
there are many beneficial forms of treatment for Tim, the evidence from
appendix 2 and the above studies suggests that there is a slight improvement
over other treatments when using MCE to decrease pain and increase functional
ability. Further study would clarify the results of this intervention.