Effects of External Focus and Motor Control Training in Comparison with Motor Control Training Alone on Pain, Thickness of Trunk Muscles and Function of Patients with Recurrent Low Back Pain: A Single Blinded, Randomized Controlled Trial

Document Type : RESEARCH PAPER

Authors

Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran

Abstract

Background: Recurrent low back pain (RLBP) affects different structures in the lumbar spine. Exercise therapy is highly
recommended as one of the first-line treatments. One crucial variable introduced to enhance RLBP is the external
focus. The present study aimed to investigate the effects of external focus training on pain, the thickness of transverse
abdominis (TrA), internal oblique (IO), external oblique (EO), and lumbar multifidus (LM) muscles, kinesiophobia, fearavoidance
beliefs, and disability of people with RLBP.
Methods: This randomized-controlled trial consisted of 38 RLBP patients. Patients were randomly divided into two groups
the treatment group (n=19) that received external focus training in addition to motor control training and the control group
(n=19) that received motor control training alone. The primary outcome was pain intensity, and secondary outcomes were
the thickness of TrA, IO, EO, LM muscles, kinesiophobia, fear-avoidance beliefs, and disability that were measured at the
baseline and after 16 sessions of interventions. The interventions were performed three sessions weekly.
Results: Reduction in pain intensity was more significant in the intervention group than in the control group (P<0.001, Cohen’s
d=-1.47). The thickness of TrA muscle in the contraction condition of the intervention group was significantly more on the left
side (P<0.001, Cohen’s d=1.05) than on the right side (P=0.03, Cohen’s d=0.44). Other outcomes showed no significant
differences. However, the Cohen’s d effect size for the left IO (Cohen’s d=0.57) and TKS (Cohen’s d=-0.53) were moderate.
Conclusion: In RLBP patients, external focus and motor control training could effectively reduce the pain. Although
this intervention could increase the thickness of the TrA muscle of RLBP, it has no significant effect on the thickness
of IO, EO, and LM muscles. In addition, the obtained results indicated that this intervention has no significant effect on
kinesiophobia, fear-avoidance beliefs, and disability..
Level of evidence: I

Keywords


1. Hoy D, March L, Brooks P, et al. The global burden of 
low back pain: estimates from the Global Burden of 
Disease 2010 study. Ann Rheum Dis 2014;73(6):968-
74. doi: 10.1136/annrheumdis-2013-204428.
2. Balague F, Mannion AF, Pellise F, Cedraschi C. Nonspecific low back pain. Lancet 2012;379(9814):482-
91. doi: 10.1016/S0140-6736(11)60610-7.
3. Hoy DG, Smith E, Cross M, et al. Reflecting on the global 
burden of musculoskeletal conditions: lessons learnt 
from the global burden of disease 2010 study and the 
next steps forward. Ann Rheum Dis 2015;74(1):4-7. 
doi: 10.1136/annrheumdis-2014-205393.
4. Tulder MV, Koes B , eds. Evidence-Based Medicine for 
Low Back Pain. in:Spinal Imaging. MR: Springer, Berlin, 
Heidelberg ;2007.
5. Da Silva T, Mills K, Brown BT, Herbert RD, Maher CG, 
Hancock MJ. Risk of Recurrence of Low Back Pain: 
A Systematic Review. J Orthop Sports Phys Ther 
2017;47(5):305-13. doi: 10.2519/jospt.2017.7415.
6. Fattahi AS, Maddah G, Motamedolshariati M, 
Ghiasi–Moghadam T. Chronic low back pain due to 
retroperitoneal cystic lymphangioma. Arch Bone Jt 
Surg 2014;2(1):72.
7. Soderberg GL, Barr JO. Muscular function in chronic 
low-back dysfunction. Spine 1983;8(1):79-85. doi: 
10.1097/00007632-198301000-00014.
8. Seraj MS, Sarrafzadeh J, Maroufi N, Takamjani IE, 
Ahmadi A, Negahban H. The ratio of lumbar to hip 
motion during the trunk flexion in patients with 
mechanical chronic low back pain according to 
o’sullivan classification system: a cross-sectional 
study. Arch Bone Jt Surg 2018;6(6):560.
9. Bystrom MG, Rasmussen-Barr E, Grooten WJ. 
Motor control exercises reduces pain and disability 
in chronic and recurrent low back pain: a metaanalysis. Spine 2013;38(6):E350-8. doi: 10.1097/ BRS.0b013e31828435fb.
10.Delitto A, George SZ, Van Dillen L, et al. Low back pain. 
J Orthop Sports Phys Ther 2012;42(4):A1-57. doi: 
10.2519/jospt.2012.42.4.A1.
11.Hides JA, Jull GA, Richardson CA. Long-term effects 
of specific stabilizing exercises for first-episode 
low back pain. Spine 2001;26(11):E243-8. doi: 
10.1097/00007632-200106010-00004.
12.Wulf G, Prinz W. Directing attention to movement 
effects enhances learning: a review. Psychon Bull Rev 
2001;8(4):648-60. doi: 10.3758/bf03196201.
13.Wulf G, McNevin N, Shea CH. The automaticity 
of complex motor skill learning as a function of 
attentional focus. Q J Exp Psychol A 2001;54(4):1143-
54. doi: 10.1080/713756012.
14.Calatayud J, Casaña J, Martí�n F, Jakobsen MD, Andersen 
LL, Colado JC. Electromyographic Effect of Using 
Different Attentional Foci During the Front Plank 
Exercise. Am J Phys Med Rehabil 2019;98(1):26-9. doi: 
10.1097/PHM.0000000000001008.
15.Hunt C, Paez A, Folmar E. The impact of attentional focus 
on the treatment of musculoskeletal and movement 
disorders. Int J Sports Phys Ther 2017;12(6):901-7.
16.Halliday MH, Pappas E, Hancock MJ, et al. A Randomized 
Controlled Trial Comparing the McKenzie Method 
to Motor Control Exercises in People With Chronic 
Low Back Pain and a Directional Preference. J Orthop 
Sports Phys Ther 2016;46(7):514-22. doi: 10.2519/
jospt.2016.6379.
17.Stanton TR, Latimer J, Maher CG, Hancock M. 
Definitions of recurrence of an episode of low back 
pain: a systematic review. Spine 2009;34(9):E316-22. 
doi: 10.1097/BRS.0b013e318198d073.
18.Critchley DJ, Coutts FJ. Abdominal muscle function 
in chronic low back pain patients: measurement 
with real-time ultrasound scanning. Physiotherapy 2002;88(6):322-32. https://doi.org/10.1016/S0031-
9406(05)60745-6
19.Koppenhaver SL, Hebert JJ, Fritz JM, Parent EC, 
Teyhen DS, Magel JS. Reliability of rehabilitative 
ultrasound imaging of the transversus abdominis and 
lumbar multifidus muscles. Arch Phys Med Rehabil 
2009;90(1):87-94. doi: 10.1016/j.apmr.2008.06.022.
20.Hides J, Richardson C, Jull G, Davies S. Ultrasound 
imaging in rehabilitation. Aust J Physiother 
1995;41(3):187-93. doi: 10.1016/S0004-9514(14) 
60429-3.
21.Kiesel KB, Uhl TL, Underwood FB, Rodd DW, Nitz AJ. 
Measurement of lumbar multifidus muscle contraction 
with rehabilitative ultrasound imaging. Man Ther 
2007;12(2):161-6. doi: 10.1016/j.math 2006.06.011.
22.Bourdon E, Ramos Jr W, Mavor MP, Beaudette SM, 
Graham RB. The effect of attentional focus on local 
dynamic stability during a repetitive spine flexion 
task. J Biomech 2018;80:196-9. doi: 10.1016/j.
jbiomech.2018.09.015.
23.Hodges PW, Richardson CA. Altered trunk muscle 
recruitment in people with low back pain with upper 
limb movement at different speeds. Arch Phys Med 
Rehabil 1999;80(9):1005-12. doi: 10.1016/s0003-
9993(99)90052-7.
24.Cholewicki J, Silfies SP, Shah RA, et al. Delayed trunk 
muscle reflex responses increase the risk of low back 
injuries. Spine 2005;30(23):2614-20. doi: 10.1097/01.
brs.0000188273.27463.bc.
25.Rowley KM, Smith JA, Kulig K. Reduced trunk 
coupling in persons with recurrent low back pain 
is associated with greater deep-to-superficial trunk 
muscle activation ratios during the balance-dexterity 
task. J Orthop Sports Phys Ther 2019;49(12):887-
98. doi: 10.2519/jospt.2019.8756. doi: 10.2519/
jospt.2019.8756.
26.Hall L, Tsao H, MacDonald D, Coppieters M, Hodges PW. 
Immediate effects of co-contraction training on motor 
control of the trunk muscles in people with recurrent 
low back pain. J Electromyogr Kinesiol 2009;19(5):763-
73. doi: 10.1016/j.jelekin.2007.09.008.
27.Hodges PW, Richardson CA. Inefficient muscular 
stabilization of the lumbar spine associated with low 
back pain. A motor control evaluation of transversus 
abdominis. Spine 1996;21(22):2640-50. doi: 
10.1097/00007632-199611150-00014.
28.Crommert ME, Ekblom MM, Thorstensson A. Activation 
of transversus abdominis varies with postural demand 
in standing. Gait Posture 2011;33(3):473-7. doi: 
10.1016/j.gaitpost.2010.12.028.
29.Foster NE, Bishop A, Thomas E, Main C, Horne R, 
Weinman J, et al. Illness perceptions of low back 
pain patients in primary care: what are they, do 
they change and are they associated with outcome? 
Pain 2008;136(1-2):177-87. doi: 10.1016/j.pain. 
2007.12.007