Archives of Physical Medicine and Rehabilitation

journal homepage: www.archives-pmr.org

Archives of Physical Medicine and Rehabilitation 2019;-:-------

ORIGINAL RESEARCH

Association Between Clinical Tests Related to Motor

Control Dysfunction and Changes in Pain and
Disability After Lumbar Stabilization Exercises in
Individuals With Chronic Low Back Pain
Crystian B. Oliveira, MSc,a Rafael Z. Pinto, PhD,b,c Siobhan M. Schabrun, PhD,d
Marcia R. Franco, PhD,b Priscila K. Morelhão, PhD,a Fernanda G. Silva, PT,a
Tatiana M. Damato, PT,a Ruben F. Negrão Filho, PhDa
From the aPhysical Therapy Department, Faculty of Science and Technology, Sao Paulo State University (UNESP), Presidente Prudente, São
Paulo, Brazil; bDepartment of Physical Therapy, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; cSydney School of
Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; and dNeuroscience Research Australia, Sydney,
Australia.

Abstract
Objective: To investigate whether clinical tests used to detect motor control dysfunction can predict improvements in pain and disability in
patients with chronic nonspecific low back pain (LBP) who have undergone an 8-week lumbar stabilization exercise program.
Study Design: A prospective cohort study.
Setting: Outpatient physical therapy university clinic.
Participants: Seventy people with chronic nonspecific LBP were recruited, and 64 completed the exercise program (NZ64).
Interventions: The lumbar stabilization program was provided twice a week for 8 weeks.
Main Outcome Measures: Pain intensity (11-point numerical rating scale) and disability (Roland Morris Disability Questionnaire) and clinical
tests, such as the Deep Muscle Contraction (DMC) scale, Clinical Test of Thoracolumbar Dissociation (CTTD), and Passive Lumbar Extension
(PLE) test. Univariate and multivariate linear regression models were used in the prediction analysis.
Results: Mean changes in pain intensity and disability following the 8-week stabilization program were 3.8 (95% confidence interval [CI], 3.2
to 4.4) and 7.4 (95% CI, 6.3 to 8.5), respectively. Clinical test scores taken at baseline did not predict changes in pain and disability at
8-week follow-up.
Conclusion: Our findings revealed that the DMC scale, CTTD, PLE test, clinical tests used to assess motor control dysfunction, do not predict
improvements in pain and disability in patients with chronic nonspecific LBP following an 8-week lumbar stabilization exercise program.
Archives of Physical Medicine and Rehabilitation 2019;-:-------
ª 2019 by the American Congress of Rehabilitation Medicine

Low back pain (LBP) is one of the most prevalent musculoskeletal
conditions worldwide. Nonspecific LBP is defined as a condition
without an attributable cause1 and represents 90% to 95% of cases
presenting in primary care settings. Although the prognosis in the
first weeks is favourable,2 15% of the adult population develop
Disclosures: S.M.S. receives salary support from The National Health and Medical Research
Council of Australia (1105040). The other authors have nothing to disclose.
Clinical Trial Registration No.: NCT02398760.
chronic symptoms.3 Individuals with chronic LBP (ie, LBP lasting
>3mo) account for a substantial proportion of the health care
costs associated with LBP.4
Motor control dysfunction is often reported in individuals
with chronic nonspecific LBP including changes in muscle
activation and movement.5 Delayed-onset muscle activity,6,7
reduced thickness of the deep abdominal muscles,8 and over-
activity of superficial muscles of the trunk9-11 are examples of
changes in muscle activation. Movement changes include an

0003-9993/19/$36 - see front matter ª 2019 by the American Congress of Rehabilitation Medicine
https://doi.org/10.1016/j.apmr.2019.01.019
2 C.B. Oliveira et al
impaired ability to dissociate movement of the lumbopelvic re-
gion from the thoracic region, maintain lumbar lordosis, and use
spinal motion as a postural strategy.12,13 Lumbar stabilization
exercises are proposed to restore coordination of the deep trunk
muscles and control of movement in people with chronic LBP.14
Although a recent Cochrane Review found low- to moderate-
quality evidence that lumbar stabilization exercises are effec-
tive to reduce pain and disability compared with minimal
intervention at all follow-up periods,15 there was moderate- to
high-quality evidence that lumbar stabilization exercises provide
similar outcomes compared with other forms of exercise.15 One
explanation for these modest effects is the heterogeneity of pa-
tients with chronic LBP recruited in the randomized clinical
trials. Indeed, recent studies suggest that lumbar stabilization
exercises might be more effective if delivered to a subgroup of
patients with specific characteristics associated with motor
control dysfunction.16,17
To identify specific changes in motor control dysfunction and
lumbar instability, clinical tests are low-cost tools that can be easily
administered in routine clinical practice. The Deep Muscle
Contraction (DMC) scale, the Clinical Test of Thoracolumbar
Dissociation (CTTD), and the Passive Lumbar Extension (PLE) test
are clinical tests recently proposed to assess motor control
dysfunction in chronic LBP. The DMC scale18 assesses the coor-
dination between superficial and deep abdominal muscles during the
abdominal drawing-in maneuver. A previous study showed that the
DMC scale is a reliable test and is able to detect changes over time.18
The CTTD19 was proposed to evaluate the patient’s ability to
perform anterior/posterior pelvic tilt in sitting with minimal or no
movement of the thoracolumbar junction. Previous studies
demonstrated that the CTTD is a reliable and valid test for assess-
ment of patients with LBP.19,20 Finally, the PLE test21 was devel-
oped to diagnose the structural lumbar segmental instability. This
test has shown moderate reliability,22 high sensitivity (84%), and
specificity (90%) and a positive likelihood ratio of 8.8 (95% confi-
dence interval [CI], 4.5-17.3) to detect radiologic lumbar segmental
instability.23 Although several clinical tests are available in the
literature for assessment of motor control dysfunctions, these 3 tests
are potentially useful in routine clinical practice because of
acceptable measurement properties in patients with chronic LBP.
Identifying the factors at initial assessment associated with
better treatment outcomes may help to develop subgroup criteria
for those patients more likely to benefit from a specific treatment.
To our knowledge, no studies have investigated the association
between motor control dysfunction at baseline, assessed by clin-
ical tests, and improved clinical outcomes in patients with chronic
nonspecific LBP. Therefore, the aim of this exploratory study was
to determine whether clinical tests used to assess motor control
dysfunction (DMC scale, CTTD, PLE test) predict improvements
in pain and disability of patients with chronic nonspecific LBP
undergoing a lumbar stabilization exercise program. We hypoth-
esized that patients with chronic LBP who scored poorly on the
clinical tests at baseline would also achieve greater reductions in
pain and disability with the lumbar stabilization exercise program.
List of abbreviations:
BMI body mass index
CTTD Clinical Test of Thoracolumbar Dissociation
DMC Deep Muscle Contraction
LBP low back pain
PLE Passive Lumbar Extension
Methods
The protocol of this exploratory prospective cohort study was
registered in clinicaltrials.gov (NCT02398760).
Participants
Individuals with chronic nonspecific LBP between 18 and 60 years
old were recruited through convenience sampling via social media
advertisement from the general community and in the outpatient
physical therapy university clinic at the São Paulo State University.
Chronic nonspecific LBP was defined as pain localized to the lower
back lasting for >3 months, not attributed to a specific pathology,
with or without radiation to the legs. In addition, to be considered
eligible for the study, participants had to score 2 points on the
numeric rating scale for the assessment of pain intensity. This cutoff
point was adopted to ensure the inclusion of participants seeking care
for their LBP. In addition, participants had to score 3 points in the
psychosocial subscale (items 5-9) of the STarT Back Screening Tool
Questionnaire24 (ie, classified as low-risk or medium-risk of poor
prognosis). According to Hill et al,24 patients in the high-risk cate-
gory represent a subgroup of LBP patients containing psychosocial
barriers who benefit from psychologically informed physiotherapy to
address physical symptoms and function as well as psychosocial
obstacles to recovery.24 Therefore, to identify participants who were
more likely to benefit solely from a lumbar stabilization exercise
program, we included only participants in the low-risk and medium-
risk categories. Two physical therapists checked the eligibility
criteria of the participants and conducted the baseline and follow-up
assessments. Before study enrollment, the participants were provided
with instructions regarding the study and signed the Informed Con-
sent Form approved by the Human Ethics Committee of São Paulo
State University (CAAE 30607214.2.0000.5402).
Participants were excluded if they met any of the following
criteria: (1) serious musculoskeletal disorders in the pelvic and
spine; (2) pregnancy; (3) previous thoracoabdominal or spine sur-
gery in the last 12 months; (4) inflammation, osteoporosis, fracture,
or tumor; and (5) signs of nerve root compromise (presence of 2 of
the following signs: reflex alterations, sensation loss, or weakness).
The recruitment of 70 participants was determined using the rule
of thumb for regression studies. The rule suggests the inclusion of 10-
15 participants for each independent variable included in the
model.25,26 Therefore, we estimated a sample size of 52 participants
would be required based on the inclusion of the 3 predictor variables
of interest (ie, DMC scale, CTTD, PLE test) and a 15% dropout rate.
However, 70 participants were recruited to enable the inclusion of
covariates (eg, age, sex, body mass index [BMI]) in the models.
Procedures
Participants attended the 2 outpatient physical therapy university
clinics before treatment to complete the baseline assessment that
included demographic information, clinical measures (ie, risk of
poor prognosis, fear of movement, depression), and clinical tests
(ie, DMC scale, CTTD, PLE test). Primary outcomes included
pain intensity and disability and were collected at baseline and
post treatment. After the baseline assessment, participants
received the lumbar stabilization exercise program at 2 outpatient
physical therapy university clinics twice a week for 8 weeks. A
trained assessor with 2 years of experience in assessing motor
control dysfunction (C.B.O.) administered the clinical tests. The
trained assessor was not involved in the treatment sessions.
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Clinical tests predicting outcomes in LBP
Instruments
At baseline, sociodemographic and anthropometric data, such as
sex, age, BMI, pain duration, and work status were collected. In
addition, we administered the STarT Back Screening Tool Ques-
tionnaire.24,27 This instrument consists of 10 items divided into 2
subscales: physical and psychosocial. Each item is scored as
positive or negative, and the sum of positive items classifies the
patients into 1 category: low risk (ie, score <3 points on both
subscales), medium risk (ie, score equal 3 points on psychoso-
cial subscale but >3 points on total score), and high risk of poor
prognosis (ie, score >3 points on psychosocial subscale).
Primary outcomes of pain intensity and disability were
collected using the following instruments:
11-point numeric rating scale28 anchored with 0 (no pain) and
10 (worst pain) used to assess the average pain intensity in the last
24 hours.
The Roland Morris Disability Questionnaire29 consists of 24
items scored from 0 (no disability) to 24 (high disability). Higher
scores indicate high disability levels. A previous study showed
that participants scoring 4 points on the Roland Morris Disability
Questionnaire may be classified as dysfunctional.30
Clinical tests
The intrarater reliability of the clinical tests administered by the
trained assessor was analyzed to ensure the precision of the
measurements. The DMC scale and CTTD demonstrated an
intraclass coefficient correlation of 0.69 (95% CI, 0.53-0.79) and
0.75 (95% CI, 0.61-0.84), respectively. A k coefficient of 0.64
(95% CI, 0.43-0.84) was obtained for the PLE test.
DMC scale
The DMC scale was proposed to assess the recruitment of the deep
abdominal muscles during the abdominal drawing-in maneuver.18,31
The total score ranges from 0-10 points and involves 5 subscales:
quality of the contraction, substitution, symmetry, breathing, and
holding. The therapist uses palpatory and observatory techniques
following the scale’s criteria. For the palpation component, the ther-
apist places the index and middle fingers medial and slightly inferior
to the anterior superior iliac spine with a gentle and firm pressure. For
the observation component, the therapist visually detects possible
compensatory strategies of the superficial abdominal muscles that
occur during the voluntary transversus abdominis contraction. Higher
scores in the DMC scale are achieved if the participants perform a
slow, gentle, and symmetrical transversus abdominis contraction with
no or little activity of superficial abdominal muscles, breathing nor-
mally and holding for at least 10 seconds.
Before assessment, participants were instructed and trained to
perform the abdominal drawing-in maneuver following a stan-
dardized verbal command proposed by Richardson et al: “Breathe in
and breathe out normally. Without breathing in slowly pull your
navel up and in toward your backbone. Hold the contraction, while
breathing normally.”32 After the familiarization process performing
2 abdominal drawing-in maneuvers following the verbal command,
participants were instructed to perform 3 abdominal drawing-in
maneuvers, with 1 minute of rest between each, and the best per-
formance was used to obtain the final score of the DMC scale.
Clinical Test for Thoracolumbar Dissociation
The CTTD was proposed by Elgueta-Cancino et al19 to evaluate
the participant’s ability to perform an anterior/posterior pelvic tilt
www.archives-pmr.org
3
with minimal or no movement of the thorax and thoracolumbar
junction. Total score of the clinical test ranges from 0-10 points
and involves 5 criteria: quality of pelvic motion, control of adja-
cent regions, directional preference, breathing, and repetition. To
achieve higher scores in the CTTD, the participants should move
the pelvis smoothly to anterior or posterior tilt with minimal
movement in the thoracolumbar junction, equal quality for both
directions, maintaining breathing in the 10 repetitions.
To perform the CTTD, participants sat in the adjusted chair, with
exposed back, hands relaxed on tights, wearing shorts without any
movement restrictions, and looking forward to a laptop screen. In-
structions to perform a correct movement were standardized using a
video provided by the authors of the test containing written in-
structions, demonstration of the movement, and the command to
perform 10 repetitions. After the video instructions, participants
were instructed to perform the movement, and the trained assessor
scored the best performance based on the CTTD’s criteria.
PLE test
The PLE test is a passive test proposed by Kasai et al21 to detect
structural lumbar segmental instability. Participants were placed in
a prone position, and the trained assessor raised both lower limbs
to a height of 30 cm while providing gentle traction. The test is
considered positive if the participant reports LBP during the test.
Kasai et al21 hypothesized that pain could result from an associ-
ation between hypermobility and lumbar instability.
Intervention
The lumbar stabilization exercise program was based on previous
research.14,31 Ten physical therapists received standardized
training by a physical therapist with 8 years of experience in
musculoskeletal rehabilitation. The training consisted of 5 hours
of lectures, practical instructions, and meetings to ensure that the
physical therapists had been implementing the protocol during the
study. Physical therapists involved in treatment administration
were not aware of the baseline assessment. The lumbar stabili-
zation exercise program involved 2 stages31 administered at 2
outpatient physical therapy university clinics twice a week over 8
weeks with each session lasting 1 hour. The first stage of the
lumbar stabilization exercise program consisted of training inde-
pendent activation of the deep trunk muscles and reducing over-
activity of the superficial trunk muscles using the abdominal
drawing-in maneuver. Physical therapists provided feedback
using palpation techniques and visual real-time ultrasonography.
Progression is achieved when participants perform 10 isolated
contractions of the deep trunk muscles for 10 seconds while
breathing normally. During the first stage, physical therapists also
introduced a training to improve the thoracolumbar dissociation
movement using standardized feedback. The training provides
feedback directed toward correcting inappropriate movement
strategies including uncoordinated movement, excessive activa-
tion of superficial muscles, or thoracolumbar extension. The sec-
ond stage of the lumbar stabilization program consisted of
increasing the exercise difficulty by first involving the superficial
trunk muscles during static tasks. Then, the physical therapists
incorporated dynamic and functional tasks (eg, household chores
or daily movements). Based on the patient’s presentation, the
physical therapists progressed and prescribed the exercises,
increasing the number of repetitions, increasing holding time, and
reducing feedback. During the second stage, exercises for thor-
acolumbar dissociation were intensified. Video instructions and a
4 C.B. Oliveira et al

regression analysis. There was also no indication of multi-

Table 1 Baseline characteristics
Characteristics Sample (NZ64)
Age (y), mean  SD 33.812.6
Female sex, n (%) 44 (69)
BMI, mean  SD 25.54.8
Pain duration (mo), median (IQR) 12 (42)
Not working, n (%) 33 (52)
SBST
Low risk, n (%) 23 (36)
Medium risk, n (%) 41 (64)
NOTE. BMI calculated as weight in kilograms divided by height in
meters squared.
Abbreviations: IQR, interquartile range; SBST, STarT Back Screening
Tool.
standardized feedback manual were used in addition to the sup-
plementary material provided by the authors of the CTTD test.
Appendix 1 details the intervention.
Data analysis
Data were reported using descriptive statistics of means  SDs,
medians with interquartile ranges, and frequencies with proportion.
Data normality was investigated using the Kolmogorov-Smirnov
test. Participants who did not complete the lumbar stabilization
exercise program were excluded from the analysis because the
objective of the study was to investigate which clinical tests could
predict better clinical improvements after this specific intervention.
To investigate the differences between baseline and follow-up
scores on pain intensity, disability, DMC scale, and CTTD, we
calculated the Wilcoxon signed-rank test because these variables
were not normally distributed. Effect sizes were also calculated for
these variables using the following formula: effect sizeZmean
difference between postintervention and baseline scores/SD of
baseline. Regarding the PLE test, we used the McNemar test to
investigate the differences between the baseline and follow-up score
and calculated the effect size using Odds Ratio.
Univariate and multivariable linear regression models were
used to investigate the association between the clinical test and
clinical outcomes. First, we conducted separate univariate linear
regressions including changes in pain intensity and disability as
dependent variables; clinical tests as independent variables; and
age, sex, and BMI as covariates. Variables associated with the
dependent variables with P.25 followed to the multivariable
collinearity as the continuous variables were not highly correlated
(r<0.6), and the variance inflation factor values for each variable
were not >2.0 in all steps. A P value of .05 was set as a criterion
for the final multivariable model, and there was no multi-
collinearity between continuous variables (r<0.5). All statistics
were performed using IBM SPSS version 20.0.a
Results
A total of 96 participants were assessed for eligibility between
July 2014 and August 2015, and 70 participants were considered
eligible. Six participants did not complete the program. Reasons
for noncompletion were (1) lack of time (nZ5) and (2) refusal to
participate with no reasons provided (nZ1). Therefore, 64 par-
ticipants (91%) completed the lumbar stabilization exercise pro-
gram. Table 1 describes the sample characteristics.
Baseline, post treatment, change scores, and effect sizes for
clinical outcomes and clinical tests after the lumbar stabilization
exercise program are described in table 2. Mean changes for pain
intensity and disability demonstrated that the intervention reduced
pain intensity by 3.8 points on a 0-10 scale (95% CI, 4.4 to
3.2) and reduced disability by 7.4 points on a 0-24 scale (95%
CI, 8.5 to 6.3).
Table 3 summarizes the univariate associations. For changes in
pain intensity, the CTTD scores and BMI were considered to be
eligible (P<.25) for the multivariable model. In the multivariable
analyses for pain, the CTTD scores did not remain in the final
model (table 4). For changes in disability, the results from the
univariate analyses showed that none of the clinical tests was
found to be eligible (P<.25) for the multivariable model.
Discussion
Our findings show that scores from the DMC scale, CTTD, and
PLE test measured at baseline do not predict improvements in
pain intensity and disability following an 8-week lumbar stabili-
zation exercise program. Our results are in accordance with recent
evidence questioning the utility of this subgroup because of
limited effectiveness, credibility, and validation.33-35
The CTTD failed to predict changes in clinical outcomes in
patients with chronic LBP undergoing an 8-week lumbar stabili-
zation exercise program. This finding aligns with recent evidence
investigating movement control dysfunctions. In fact, a recent

Table 2 Changes of the clinical outcomes after a lumbar stabilization exercises program
Variable Baseline (NZ64) Post Treatment (NZ64) Changes (95% CI) or [IQR] Effect Size P Value
NRS pain 6.41.6 2.52.3 3.8 ( 3.2 to -4.4) 2.6 <.01
7.0 [5.0-7.7] 2.0 [0-4.0] 4.0 [2.0-5.0]
RMDQ 10.93.9 3.54.0 7.4 ( 6.3 to 8.5) 1.9 <.01
11.0 [8.0-13.0] 2.0 [0-5.0] 7.0 [4.0-10.7]
DMC scale 5.11.5 8.41.1 3.3 (2.8 to 3.8) 2.2 <.01
5.0 [4.2-6.0] 9.0 [8.0-9.0] 3.0 [2.0-4.0]
CTTD 4.62.0 6.92.1 2.3 (1.7 to 3.0) 1.1 <.01
5.2 [3.0-6.2] 7.5 [6.5-8.0] 2.5 [0.6-4.4]
PLE test, n (%) 45 (70) 13 (20) 32 (37.6 to 63.4) OR, 0.11 (95% CI: 0.05 to 0.24) <.01
NOTE. Data are mean  SD or median [IQR] unless otherwise denoted.
Abbreviations: IQR, interquartile range; OR, odds ratio; NRS, numeric rating scale; RMDQ, Roland Morris Disability Questionnaire.

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Clinical tests predicting outcomes in LBP 5

Table 3 Univariate regression analyses for identification of candidate variables for multivariable regression models
Changes in Pain (NZ64) Changes in Disability (NZ64)
Variable B (95% CI) P Value B (95% CI) P Value
Age 0.01 ( 0.05 to 0.04) .87 0.02 ( 0.10 to 0.07) .72
Sex 0.30 ( 0.96 to 1.57) .63 0.60 ( 2.95 to 1.75) .61
BMI 0.10 ( 0.02 to 0.22) .09 0.17 ( 0.05 to 0.40) .12
DMC scale 0.13 ( 0.26 to 52) .52 0.01 ( 0.73 to 0.72) .98
CTTD 0.19 ( 0.48 to 0.10) .20 0.28 ( 0.83 to 0.27) .31
PLE test 0.65 ( 1.92 to 0.62) .31 0.17 ( 2.22 to 2.57) .88
NOTE. B (95% CI) indicates unstandardized B coefficient (95% CI).

study36 investigated the effectiveness of the movement system
impairment compared with general exercises. Movement system
impairment consists of an intervention using a classification sys-
tem targeting the reduction of compensatory movements and
postures commonly associated with LBP.37 Azevedo et al
demonstrated a lack of significant difference between groups in
pain intensity and disability of patients with chronic LBP.36
Therefore, although specific strategies are effective in correcting
impaired movement dysfunctions,38 they might not be associated
with clinical improvement in patients with chronic LBP.
Another finding from this study was the lack of association be-
tween the DMC scale and the changes in clinical outcomes. This
finding is in accordance with a recent systematic review39 showing
that baseline characteristics of deep trunk muscles, such as trans-
versus abdominis and lumbar multifidus, do not predict clinical out-
comes after conservative management. Several factors support the
lack of association between deep trunk muscles and clinical out-
comes, including that changes could be considered a consequence
rather than the cause of LBP40-42 and patients may use different types
of strategies regarding deep trunk muscle activation.43
Similar to the previous clinical tests, the PLE test was not
associated with changes in clinical outcomes following the 8-
week lumbar stabilization exercise program. To our knowledge,
no study has investigated the association of this test with clinical
outcomes. However, other clinical tests used to identify the
lumbar structural instability have been studied. For example,
Hicks et al44 developed a clinical prediction rule to identify pa-
tients with LBP that would respond successfully to a lumbar
stabilization program. The prone instability test45 and 3 other
clinical features (ie, age, straight leg raise, and aberrant lumbar
movement present) were able to detect patients who successfully
complete the lumbar stabilization program.44 The difference be-
tween the findings from Hicks et al44 compared with ours may be
because of the analyses of a high number of predictors (nZ44)
using a relatively small sample (nZ54). In contrast, our study
powered the analyses using 10-15 participants per predictor var-
iable. Nevertheless, a recent trial supports the lack of interaction
between this clinical prediction rule and the lumbar stabilization
exercise program.46
Study limitations
The main limitation of our study was the lack of a comparator
group. This would allow us to compare whether the subgroup of
those with motor control dysfunction would indeed respond to
motor control intervention in comparison with a less specific
intervention (ie, general exercise or usual care).47 In addition, our
sample was restricted to individuals with chronic nonspecific LBP
with low risk or medium risk of poor prognosis based on the
STarT Back Screening Tool Questionnaire, which may restrict the
generalizability of our findings. Future studies should investigate
if similar findings exist in people with acute and subacute LBP.
Considering the limited evidence supporting instruments to
determine poor outcome risk,48 further studies should be con-
ducted without selecting the sample based on the risk of poor
prognosis. Another limitation is that our sample was relatively
young with a mean age of 33.8 years, so generalization of our
results to other age groups should be done with caution. Finally,
although the clinical tests used in this study showed poor to
moderate reliability (ie, DMC and CTTD scales) or substantial
agreement (ie, PLE test), they are subjective assessments relying

Table 4 Multivariate linear regression analysis with changes in pain as dependent variable, clinical tests at baseline, and changes as the
independent variables and the potential covariates
Model Steps Variables R2 (Adjusted R2) B (95% CI) P Value
Dependent variable: changes in pain intensity (NZ64)
Base model Constant (%) 6 (3)
BMI 0.09 ( 0.03 to 0.21) .12
CTTD 0.16 ( 0.45 to 0.13) .28
Final model None of the variables remained in the final model
Dependent variable: changes in disability (NZ64)
Base model Constant (%) 4 (2)
BMI 0.17 ( 0.05 to 0.40) .12
Final model None of the variables remained in the final model
NOTE. B (95% CI) indicates unstandardized B coefficient (95% CI).

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6 C.B. Oliveira et al

on the therapists’ judgements. Future studies should investigate Supplier

other valid clinical tests against objective measures49 as well as
objective methods for assessment of motor control dysfunctions, a. SPSS version 20.0; IBM.
such as kinematic measures, to predict clinical improvements of
patients with LBP.

Keywords
Conclusions
Low back pain; Exercise therapy; Outcome and process
Our findings revealed that the DMC scale, CTTD, and PLE test assessment (health care); Rehabilitation
clinical tests assessing motor control dysfunctions do not predict
improvements in pain intensity and disability in patients with
chronic nonspecific LBP undergoing an 8-week lumbar stabili-
zation exercise program. The results from this study do not sup-
Corresponding author
port claims that it is possible to identify a subgroup of patients Crystian B. Oliveira, MSc, Rua Maria Aparecida, 456, Jardim
with chronic LBP who would respond to a course of lumbar sta- Santa Helena, Presidente Prudente 19015-620, SP, Brazil. E-mail
bilization exercise program with clinical tests. address: crystianboliveira@gmail.com.

Appendix 1 Description of the intervention using the template for intervention description and replication checklist
1. Brief name Lumbar stabilization exercises program
2. Why LBP is one of the most disabling conditions imposing an enormous economic burden to society and individuals.
Motor control dysfunction is often reported in individuals with chronic nonspecific LBP including changes in
muscle activation and movement. Recent studies suggest that lumbar stabilization exercises might be more
effective if delivered to a subgroup of patients with specific characteristics associated with motor control
dysfunction. The aim of this exploratory study was to determine whether clinical tests used to assess motor
control dysfunction (DMC scale, CTTD, PLE test) predict improvements in pain and disability of patients with
chronic nonspecific LBP undergoing a lumbar stabilization exercise program.
3. What materials The physical therapists administering lumbar stabilization exercises could use the following equipment in the
second stage of the program: elastic bands, Swiss ball, or balance boards. In addition, the video instructions
for performing the thoracolumbar dissociation was provided using smartphones or laptops.
4. What procedures Participants attended the outpatient physical therapy department before treatment to complete the baseline
assessment including the clinical tests. A trained assessor with 2 years of experience in assessing motor
control dysfunction administered the clinical tests. Clinical outcomes included pain intensity and disability
and were collected at baseline and post treatment. After the baseline assessment, participants received the
lumbar stabilization exercise program twice a week for 8 weeks.
5. Who provided Ten physical therapists received standardized training by a physical therapist with 8 years of experience in
musculoskeletal rehabilitation. Physical therapists involved in treatment administration were not aware of the
baseline assessment.
6. How The first stage consisted of training independent activation of the deep trunk muscles and reducing overactivity
of the superficial trunk muscles using the abdominal drawing-in maneuver. Physical therapists provided
feedback using palpation techniques and visual real-time ultrasonography. Progression was achieved when
participants could perform 10 isolated contractions of the deep trunk muscles for 10 seconds while breathing
normally. During the first stage, physical therapists also introduced a training aiming at improving the
thoracolumbar dissociation using standardized feedback. The training provides feedback orientation
correcting inappropriate strategies, such as uncoordinated movement, excessive activation of superficial
muscles, or thoracolumbar extension. The second stage consisted of increasing the exercise difficulty,
involving the superficial trunk muscles, first using static and then dynamic, functional tasks. The physical
therapists progressed the exercises based on the patient’s presentation, increasing the number of repetitions,
increasing holding time, and reducing feedback. During the second stage, exercises for thoracolumbar
dissociation were intensified. Video instructions and a standardized feedback manual were used in addition to
the supplementary material provided by the authors of the CTTD test.
7. Where The trial was conducted at 2 outpatient physical therapy clinics in Presidente Prudente, Sao Paulo, Brazil.
8. When and how much Participants received the lumbar stabilization exercise program twice a week for 8 weeks between July 2014 and
August 2015.
9. Tailoring The physical therapists progressed the exercises based on the patient’s presentation, increasing the number of
repetitions, increasing holding time, and reducing feedback.

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Clinical tests predicting outcomes in LBP
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