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. Author manuscript; available in PMC: 2020 Aug 3.
Published in final edited form as: Disabil Rehabil. 2018 Apr 12;41(17):2071–2079. doi: 10.1080/09638288.2018.1460627

Motor skill training in musculoskeletal pain: a case report in chronic low back pain

Vanessa M Lanier a,b, Catherine E Lang a,c,d, Linda R Van Dillen a,b
PMCID: PMC7398488  NIHMSID: NIHMS1612984  PMID: 29644888

Abstract

Purpose:

Low back pain is a chronic condition that limits function. The chief reason individuals with low back pain seek care is difficulty performing functional activities. A novel approach to improving performance of painful and limited functional activities is motor skill training, defined as challenging practice of activities to learn or relearn a skill. The purpose of this report is to describe the design and application of a motor skill training intervention in a 26-year-old man with a 10-year history of low back pain.

Methods:

A motor skill training intervention was implemented to modify the altered alignment and movement patterns he used during the performance of his painful and limited activities.

Results:

The patient was seen for six visits in 12 weeks. The patient reported decreased pain and medication use, as well as improved function immediately, 3-, and 9-months post-intervention.

Conclusion:

Individuals with low back pain report limitation in ability to perform everyday functions and demonstrate altered patterns of movement and alignment during these activities. This case report describes an innovative motor skill training intervention that directly addresses the performance of functional activities and the application of motor learning principles.

Keywords: Motor learning, lumbar spine, spine, skill training, low back pain

Introduction

Low back pain (LBP) is a costly chronic condition that impacts function. At least 60–80% of adults will experience LBP [1] and 75% of people with an episode of LBP fail to recover fully within 1 year [2]. Pain persists as do limitations in simple movements and complex functional activities like self-care, social roles, and work [3]. Furthermore, recurrence rates are as high as 78% [4]. For many people LBP is a long-term condition that limits function [5]. In fact, the primary reason individuals with chronic LBP seek repeat visits for medical care is for difficulty performing everyday functional activities [6].

LBP is multifactorial with both biophysical and psychosocial components [7]. Various non-surgical interventions for LBP have been investigated addressing the biophysical, psychosocial, or both components. These interventions have included exercise, manual therapy, and behavioural interventions, to name just a few [8-11]. Reviews of these interventions have revealed positive effects for LBP. However, the effect sizes are typically small, and there is no consistent evidence that any particular type of exercise or behavioural intervention is more efficacious than any other [8-11]. Multimodal biopsychosocial interventions have been advocated to address the contribution of both biophysical and psychosocial components to a person’s LBP [12-15]. A challenge of multimodal interventions, however, is that it is difficult to determine the extent to which individual components of the intervention contribute to improvements in outcomes. It is logical, however, that each component of the intervention be delivered with an appropriate method and dose.

Exercise is the most common approach to directly addressing the biophysical contributors to LBP [16]. Traditional exercise interventions for LBP typically target specific impairments such as trunk strength and lower extremity flexibility, rather than performance of functional activities [17]. Although traditional exercise interventions result in improvements in outcomes, effect sizes are small to moderate and primarily attained at early follow-up [18]. Additionally, because functional activities are not explicitly practiced, the link between improvement in impairments and improvement in performance of functional activities is unclear. Some have included training in functional activities as a component of interventions for LBP [9,19-26], but the description of the training is minimal and it is delivered with other interventions such as motor control exercises [9,19-26], behavioural interventions [9], modalities [23], manual therapy [23], and education [24]. As such, the effect of training in functional activities is unclear.

People with LBP display altered patterns of movement and alignment that are frequently associated with their symptoms [27-33]. These patterns are proposed to begin as the result of an interaction between characteristics of the individual and the movements and alignments needed to perform activities [34-36]. Over time, the same patterns are used for many different activities, with the typical pattern characterized by the lumbar spine moving more readily in a specific direction(s) than the thoracic spine or hip [31,37-40]. Additionally, systematically modifying these patterns decreases LBP during painful tasks [41-43]. Given that people with LBP display altered patterns of movement and alignment during functional activities and the profound impact of LBP on function [3], a logical approach to intervention requires explicit, individualized practice in performance of functional activities to achieve more optimal movement and alignment patterns, improve functional limitations and decrease symptoms.

One such approach is motor skill training. Motor skill training involves challenging, repetitive practice of activities applying motor learning principles to learn or relearn a motor skill. Motor skill training induces structural and functional adaptations across a variety of motor regions of the nervous system [44-46]. Such adaptations are associated with the acquisition of new motor skills and vary with the degree of motor skill a person displays [47,48]. In contrast, strength and endurance exercises do not produce these adaptations [49,50]. If a goal of LBP rehabilitation is to aid acquisition, retention, and refinement of new motor behaviours to improve function, then the use of motor skill training is a necessity to modify the altered patterns that the person typically uses during his symptom-provoking functional activities. Such training specifically addresses the performance of painful and limited activities, rather than assuming that the benefits of exercise will generalize to performance of everyday functional activities. Motor skill training to improve altered movement and alignment patterns within the context of symptom-provoking functional activities is novel in studies of people with musculoskeletal pain conditions [51,52]. While others have included training in functional activities as a component of interventions for LBP, the training is delivered with other interventions [9,19-26], and not described in sufficient detail to determine if the conditions facilitate learning. The purpose of this case report, therefore, is to describe the design, application, and outcomes of a motor skill training intervention in an individual with chronic LBP.

Case description

The patient was a 26-year-old male referred to physical therapy for LBP. He provided informed consent for treatment and submission of his case for publication. He had no imaging studies and his medical history was unremarkable. He reported a 10-year history of LBP, with initial onset at age 16 following lifting. He continued to experience LBP when he played competitive tennis in high school and college. Six years later, in law school, he reported daily pain. In the six months prior to intervention, he reported aggravation of symptoms while studying for the legal bar examination. During this period, he took 400 mg of ibuprofen twice daily for pain. He maintained an active lifestyle, running daily, performing yardwork, and house chores, but with frequent breaks secondary to pain. He had no history of rehabilitative interventions for his LBP.

He reported daily LBP in the central mid- and lower-lumbar regions, radiating into the left buttock. His symptoms worsened with sitting and working at his desk, washing the dishes, cooking, mowing the lawn, turning in bed, and driving his car. Changing positions and walking decreased his symptoms. His goals were to: (1) sit and work at his desk for 1.5 h without a standing break, (2) stand for an hour to cook and wash the dishes without taking a break, and (3) sleep through the night.

Examination/assessment

The patient reported chronic LBP that affected his performance during a variety of functional activities, indicating that he might be a good candidate for motor skill training. His symptoms worsened with activities involving flexion, rotation, and lateral bending of his lumbar spine. A standardized examination was performed as previously described to determine his LBP classification to guide the training [53]. The examination focused on identifying whether the patient displayed a consistent pattern of altered alignment and movement patterns of the lumbar spine in a specific direction(s). We used a classification system because of evidence to support the existence of LBP subgroups [54-57] and a meta-analysis of intervention studies [58] showed added benefit to outcomes of individualized intervention. His LBP classification was named for the directions of altered alignments and movement patterns that he consistently displayed across clinical tests. These directions were associated with symptoms and, when systematically modified, improved the symptoms. He was classified with a Movement System Impairment diagnosis of lumbar rotation with flexion syndrome. Therapists are reliably able to determine a Movement System Impairment classification following a standardized examination [59-63]. Motor skill training was selected to change the alignment and movement strategies he used during functional activities.

Intervention

The patient was seen for six, 60-min visits in 12 weeks. The motor skill training intervention involved challenging practice of his functional activities in ways that: (1) minimized use of his stereotypic lumbopelvic movement and alignment patterns (flexion, rotation, and lateral bending), and (2) encouraged use of other joints (thoracic spine, hips, knees) to complete the activity painlessly. Thus, rather than prescribing exercises for individual trunk muscles, the intervention was aimed at modifying how he used multiple trunk muscles within the context of the activity. Table 1 summarizes the motor skill training intervention. The first column outlines the motor learning principles that guided the training. The second column describes how the motor learning principles can be implemented in the treatment of LBP generally. The third column details how the principles were applied to the patient in this case.

Table 1.

Motor learning principles and implementation in intervention for low back pain.

Principle Implementation for low back pain Implementation for patient
Learning does not occur without feedback Patient is educated about movement classification and primary contributors to low back pain Extrinsic visual, auditory, and tactile feedback utilized, but progressed to intrinsic as soon as possible
Intrinsic feedback is best for encouraging generalization and self-learning Feedback is provided with the goal of minimizing extrinsic feedback and encouraging the patient to attend to intrinsic feedback Use questions to direct patient to attend to intrinsic feedback
– What do you specifically notice that lets you know that you are not twisting your back?”
– This time when you perform the movement, I want you to focus on what you feel that lets you know you are twisting your back”
Optimal learning happens when individuals are motivated and engaged Patient selects activities to increase engagement Activity selection Patient instructed to select frequently performed activities that were painful or difficult because of his low back pain and that he wanted to be able to perform without pain. Patient selected performing activities in sitting, performing activities in standing, and bed mobility
Improvement in a movement is obtained through practicing that movement Practice using the appropriate alignment pattern, movement pattern, and muscle activation during functional activity
Make every attempt to simulate functional environment and practice in context		 Practice conditions Example: Patient practiced washing at a sink, retrieving dishes from an overhead cabinet and placing them to the right of the sink to dry; the setup he described for his home kitchen
Mastering a motor skill requires large amounts of practice Accomplished in session Practice activity for 15–20 min/intervention session, materials available, and environment is structured to allow for continuous practice. Rest breaks provided only when requested by the patient or if low back pain symptoms begin to increase over the practice
Accomplished at home Home program: Specific practice of the most challenging level of skill that he could perform correctly during session and applies principles learned in intervention sessions to similar daily activities		 Example, standing activities practiced in one session without rest breaks:
– Sweeping, cooking, placing and removing objects from the refrigerator, vacuum, lawn mower, grocery shopping, laundry, don/doff shoes
Learning necessitates solving motor problems not repeating over-learned tasks Tasks are graded to make them more or less difficult within an intervention session and across sessions Example, washing dishes:
– Progress from small object (bowl) to larger irregularly-shaped object (pot)
– Progress from placing object on counter-top to placing object on a low shelf
Variable conditions of practice promote learning and generalization Variation is accomplished within activities by grading the activities and changing the practice context Variation is accomplished across tasks by practicing at least three activities/session Example, practicing reaching in sitting:
– Practice retrieving files from desk in simulated office (back rest, desk-height)
– Practice retrieving glass from table while sitting at simulated bar (no back rest, higher surface)
Practicing an entire task results in superior learning compared to practicing of parts of the task, unless the task can be partitioned into plainly separable components Basic underlying movement components of muscle contraction and timing and grading of movement excursion of the hip, lumbar, and thoracic areas as performed during functional activities Example, practicing retrieving an object from shelf at grocery store
– DO: Practice retrieving objects from a shelf. If overly challenging, then decrease shelf-depth or object weight
– DO NOT: Practice forward bending in isolation as an exercise assuming it will translate to lifting
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Motor learning principles developed based on recent reviews.

Education

At his initial visit, the patient was educated about his diagnosis and how it related to his LBP (Table 2). It was essential for him to understand the errors he was making in order to change his movement and alignment (Table 1).

Table 2.

Individualized patient education.

The primary contributors to your low back pain symptoms are repeated movements and prolonged positions of bending, twisting, and side bending
 • You repeat movements and positions of bending, twisting, and side bending across the day during all daily activities
 • The repetition irritates your low back tissues, resulting in low back pain symptoms
 • Your symptoms persist or recur because you move in the same direction all day and constantly irritate your low back tissues
 • Your intervention focuses on modifying or changing how you perform daily activities so that you do not flex, rotate, or side bend your low back repeatedly across the day
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Activity selection

Following education, specific activities were selected to practice. Activities were selected that were difficult or painful for him to perform because of his LBP. As per the principles in Table 1, he was included in selection of the activities. He was encouraged to select the activities that he frequently performed, since these would have the greatest impact on his function. He selected sitting activities, standing activities, and bed mobility.

Current and goal level of function

His current level of function then was determined for each activity, including the typical painful situations he encountered (Table 3). This was the starting point for practice. His goal level of function was set at the most challenging version of the activity he needed to perform during daily function (Table 3).

Table 3.

Patient’s current level of function, goal level of function, and performance level at final visit.

Activity Current level of function Goal level of function Performance level at final visit
Standing Stands for 15 min before taking a break secondary to low back pain. Pain increases with washing dishes, donning/doffing shoes, retrieving objects from different heights, and mowing the lawn Stand for 60 min to cook dinner and clean the dishes without a break Performs the following without increased symptoms:
Stands for 60 min to cook dinner and cleans dishes without a break
Mows the entire lawn without a break Runs first thing in the morning
Sitting Sits for 20 min before taking a break secondary to low back pain. Pain increases with checking second computer screen placed 0.5 m to the left of his laptop, reading document on third computer screen to the right, answering phone, taking notes Sit for 90 min in a standard office chair at a desk. Check second computer screen placed 0.5 m to the left of his laptop, read document on third computer screen to the right, take notes on laptop, answer phone to the right Performs the following without increased symptoms:
Sits for 90 min in a standard office chair at a desk. Checks computer screens to the left and right of his laptop, takes notes on laptop, answers phone to the right
Sits without back support for 60 min on a bar stool at a restaurant
Bed mobility Awakens 6×/night secondary to pain.
Pain increases with getting in/out of bed, pain with rolling		 Sleep through the night without awakening secondary to pain. Get in and out of bed and roll in standard height bed with two dogs, fiancé, and bed covers Performs the following without increased symptoms:
Gets in and out of bed and rolls in standard height bed with fiancé and bed covers (dogs no longer allowed in bed)
Sleeps through the night without awakening secondary to pain
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The patient was seen for six, 60-min visits in 12 weeks.

Practice conditions

After the patient identified the exact context of the activities he needed to perform, the space was arranged to mimic the specific details of his environment. The space included a set up for the patient to practice common household and work activities, including a bed, desk, and sink. It was important for him to practice in an environment that simulated the typical situations he faced during his day (Table 1). Placement of the objects within the environment, environmental constraints, and the temporal aspects of the activity were considered during practice. While all formal practice with the therapist occurred at our facility, feedback was obtained from the patient about how he managed in his own environment.

Feedback

Feedback was provided during training to help the patient identify movement and alignment errors because learning does not occur without feedback [64]. Visual, tactile, and auditory feedback were used. The goal was to minimize extrinsic feedback and encourage him to attend to intrinsic feedback (Table 1). We operationally defined intrinsic feedback as internal feedback from the sensory systems and extrinsic feedback as additional feedback from an external source. Thus, the feedback provided was the least-directive necessary and was removed as soon as possible. Table 4 provides an example of how feedback was provided while practicing sweeping.

Table 4.

Feedback while practicing sweeping the floor – Visit 4.

Dialogue between patient and therapist Feedback provided
PT: Show me how you’ve been practicing sweeping at home (Pt performs sweeping, with side bend to the right) Ask patient to demonstrate movement and self-evaluate performance
PT: We practiced this activity last week. How do you think your back is moving as you sweep?
Pt: I think I’m moving well
PT: I think you are doing better than last week, but I notice that you are side bending to the right as you sweep. Try sweeping again and see if you can feel what I am noticing. (Pt tries sweeping and continues to side bend to the right) If patient is unable to identify movement “error”, then provide verbal feedback and see if patient can identify movement correctly
Pt: I feel like I am straight
PT: I still notice side bending to the right. I am going to show you in the mirror so that you can see what I am noticing (PT brings mirror, and pt practices sweeping with visual feedback) 		If patient is still unable to identify movement “error”, then provide visual feedback and see if patient can identify movement correctly
Pt: Now I can see that I am side bending to the right (Pt adjusts performance and no longer side bends to the right when using visual feedback)
Pt: Does that look better to you? I do not think I’m side bending anymore		 Once patient is able to identify and correct movement “error” with extrinsic visual feedback, then direct him to attend to intrinsic feedback
PT: I agree. I think that your movement looks a lot better. Go ahead and practice a few more times with the mirror. I want to you pay attention to what you feel that lets you know when you are side bending and when you are not (Pt practices several times with mirror)
Pt: When I do not side bend I feel like I’m lifting my right shoulder
PT: OK, good. Now I’m going to take the mirror away and see if you can maintain the same movement pattern without the mirror for feedback (Pt performs sweeping without side bending) Once patient is able to identify internal cues while practicing with visual feedback, then remove visual feedback
PT: Do you think that you did any bending, twisting, or side bending that time?
Pt: No, I think I moved well
PT: I agree. Go ahead and practice a few more times to make sure that you can remember how it feels when you go home
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PT: physical therapist; Pt: patient.

Practice time

Mastering a motor skill requires large amounts of practice [65-67]. Practice time was maximized in three ways (Table 1). First, activities were practiced for 15–20 min per session. Second, the patient was prescribed a home program of practicing the most challenging level of the skill that he could perform correctly during the session for 10 repetitions, twice daily. For example, his home program for activities in standing after his first visit was to practice retrieving a dish from the sink and placing it on a drying rack to the side of his sink 10 repetitions, twice daily. Third, he was asked to apply the principles practiced during intervention sessions to all daily activities. For example, at visit 1 he practiced sitting at his desk, manipulating objects on his desk, answering the phone, and checking a security screen. The activity was practiced modifying his altered pattern of lumbar flexion, rotation, and lateral bending. Following the session, he was encouraged to apply the principles he practiced to all other daily sitting activities.

Progressing activities

Activities were initially practiced at the current level of function as described by the patient (Table 3). For example, for standing activities, the patient practiced standing at the sink and washing a dish. When he could modify his movement and alignment and control his LBP during a given activity, the difficulty was increased by changing specific aspects of the activity. For example, the difficulty of doing the dishes was increased by washing a larger object and manipulating the dishes more quickly. At each intervention session, a standardized measure [68] was used to assess his independence with his home program and decide if he could progress to a higher level of difficulty or move to a new activity. As independence and mastery of skills increased, activities were progressed from more simple to more complex. For example, initially the patient practiced washing a small dish and placing it on a drying rack. By the end of the training, he practiced washing dishes of varied sizes and placing them in different locations in the kitchen (overhead cabinet, low cabinet, drying rack) with the distraction of conversing with the therapist. Table 5 describes activity progression across intervention sessions.

Table 5.

Progression of activities across intervention sessions.

Progression of standing activities
Visit 1 Standing alignment, dishes
Visit 2 Dishes, refrigerator
Visit 3 Dishes, cooking, don/doff shoes, sweeping, vacuum, lawn mower, grocery store, laundry
Visit 4 Sweeping, cooking, refrigerator, vacuum, lawn mower, grocery store, laundry, don/doff shoes
Visit 5 Laundry, grocery store, lawn mower, running, cooking
Visit 6 Grocery store, dishes, cooking, lawn mower, sweeping, running
Progression of bed mobility
Visit 1 Right (R) side lying to supine with pillow between knees, no covers
Visit 2 Sitting to R side lying to supine with pillow between knees, no covers
Visit 3 Sitting to R side lying to supine with pillow between knees, no covers
Visit 4 Sitting to R side lying to supine to left (L) side lying with pillow between knees, no covers
Visit 5 Sitting to R side lying to supine to L side lying to sitting with pillow between knees and covers
Visit 6 Sitting to R side lying to supine to L side lying to sitting with pillow between knees and covers, quickly
Progression of sitting activities
Visit 1 Office chair with back support, scoot left to check screen, answer phone
Visit 2 Office chair with back support, scoot left to check screen, answer phone, take notes
Visit 3 Office chair with back support, retrieve object from low file drawer
Visit 4 Office chair with back support, alternating quickly between tasks, sitting in soft and low chair
Visit 5 Bar stool without back support, reach for objects on table, eat, drink
Visit 6 Office activities, bar stool eating, couch activities
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Measures

Measures of pain, function, medication use, and adherence were collected at each clinic visit and with electronic questionnaires at 3- and 9-months post-intervention. LBP-related functional limitation was measured using the Modified Oswestry Disability Index. The Modified Oswestry Disability Index is reliable, valid, and sensitive to change when compared with other measures of LBP-related limitation [69]. Symptom intensity was measured using the verbal numeric rating scale. An 11-point scale (0–10) was used to measure current pain, as well as average and worst pain over the prior 7 days. Verbal numeric rating scale measurements are reliable and valid [70], and provide sufficient levels of discrimination to describe pain intensity at varying levels of acuity [71]. Adherence was tracked using a standardized self-report measure. The patient marked his daily adherence to the prescribed intervention on a 10-cm horizontal line from “0%” to “100%” adherence. The patient was asked to also estimate his average percent adherence since his last visit. Daily logs and estimated average percent adherence were compared for consistency. Patient estimates of average percent adherence have been shown to be consistent with that recorded in daily adherence logs [21]. Frequency of medication use also was tracked, since minimizing nonsteroidal anti-inflammatory drugs and other pharmaceutical use is an important outcome of intervention [72].

Outcomes

By the end of the 12-week intervention, the patient reached his goal level of function for standing and sitting activities, and bed mobility (Table 3). Self-reports of pain, functional limitation, and medication use decreased over the intervention and continued to improve at the 3-month follow-up (Table 6). The magnitude of the changes in function exceeded published values of minimal-clinically important changes at the end of the active intervention phase and at 3- and 9-month follow-up [69]. His pain and function did minimally regress at 9-month follow-up;however, improvements remained compared to his baseline measures.

Table 6.

Intervention outcomes.

Visit 1 Visit 2
1 week later		 Visit 3
2 weeks later		 Visit 4
1 week later		 Visit 5
1 week later		 Visit 6
6 weeks later		 3 months
post-intervention		 9 months
post-intervention
Pain (0–10)
 Currenta 6 3 4 2 2 1 1 2
 Average in past weeka 4 3 3 3 2 2 2 3
 Worst in past weeka 8 5 4 4 3 3 3 6
Modified Oswestry Disability Index (0–100%) 30 30 26 18 6 4 2 8
Adherence (0–100%) Average since n/a 75% 75% 85% 85% 80% 80% 65%
last visit or in the past weekb
Ibuprofen use (frequency/day) 400 mg 2×/day 400 mg 2×/day 400 mg 2×/day 400 mg 1×/day 400 mg 2×/week 400 mg 2×/week 400 mg 2×/week 400 mg 1×/week
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a

Verbal estimate of symptom intensity using an 11-point scale (0–10).

b

Verbal estimate of average percent adherence since the last visit (active intervention phase) or in the past week (3 and 9 months post-intervention).

Discussion

We have described a motor skill training intervention for an individual with chronic LBP focused on employing motor learning principles to modify the movements and alignments he used during his everyday life. His function improved as assessed by both the Modified Oswestry Disability Index and his performance of the activities practiced during the intervention. Traditional exercise interventions target impairments, such as decreased trunk strength and flexibility, but our novel approach directly addresses functional activities by modifying altered movements, alignments, and muscle activation within the context of performance of these activities, including the practical application of motor learning principles [17].

Because the motor skill training intervention is based on motor learning principles, the way feedback was provided during this intervention was different from the way it is routinely provided during clinical practice. The goal was to provide the least-directive feedback necessary and to remove it as soon as possible. The therapist focused the feedback on helping the patient self-identify errors and problem-solve solutions, rather than pointing out his errors and suggesting solutions. Intuitively, this should facilitate problem-solving during novel activities outside of therapy sessions and promote self-efficacy. Low self-efficacy has been identified as a barrier to adherence to physical therapy [73]. In fact, cognitive behavioural therapy interventions encouraging patient problem-solving have demonstrated improved patient self-efficacy compared to traditional patient education [74].

While adherence is important for efficacy [18], low adherence to traditional physical therapy interventions presents challenges [75]. A home program of practice of functional activities is a promising solution. Previous work has reported higher adherence to functional activity training than exercise performance, with associated improved outcomes [21]. Here, the patient reported high adherence during both the intervention phase (75–85%) and post-intervention (80% and 65%). Because his home program involved practicing functional activities, he could incorporate his practice into his regular activities rather than setting aside time to perform traditional exercises.

The motor skill training intervention described in our case report targeted the mechanically-related processes we believed contributed to the patient’s LBP presentation, but other factors could have contributed to his outcomes. LBP-related disability is multi-factorial and influenced by both biophysical and psychosocial factors [15]. The motor skill training intervention exposed him to increasingly difficult activities, and it is possible that the therapist’s encouragement improved his fear of movement and re-injury. However, motor skill training is distinct from interventions such as graded exposure because the focus is on painlessly performing challenging skills based on his motor capabilities rather than systematic exposure to fearful activities regardless of pain [76]. Additionally, while we did not administer a self-report measure of fear-avoidance or kinesiophobia, the patient was not avoidant of painful activities prior to the intervention, including running and yardwork.

Although motor skill training interventions addressing function in people with LBP have been understudied, the effects of motor skill training on the specific skill of muscle activation of the transversus abdominis during a laboratory task have been examined in three small studies [77-79]. Pain and function were measured in two trials [78,79]. While pain improved in both studies, function only improved in one [78]. Furthermore, improvements in pain and function were minimally related to changes in transversus abdominis activation. These earlier studies provide evidence that motor skill training can be implemented in people with LBP. The difference, however, is that a laboratory task was targeted rather than a functional activity. A systematic review reported no association between changes in transversus abdominis activation or morphometry and changes in clinical outcomes following conservative management of LBP [80]. This case report provides a framework for a motor skill training intervention that specifically addresses the performance of painful and limited functional activities.

This case report describes the implementation of motor skill training in functional activities for a person with chronic LBP. The intervention is based on motor learning principles, but has not been evaluated for its efficacy. A single-blind, randomized, controlled trial is underway to test the efficacy of functional motor skill training compared to traditional strength and flexibility exercise for people with chronic LBP (ClinicalTrials.gov Identifier: NCT02027623). Because motor skill training is an intervention strategy aimed at modifying stereotypic patterns that a person uses during the performance of his functional activities, we speculate that a similar approach could be applied to other musculoskeletal conditions where strategies of movements and postures used across the day are associated with a person’s pain and functional limitations.

IMPLICATIONS FOR REHABILITATION.

  • Low back pain is a chronic condition that limits function.

  • The chief reason individuals with chronic low back pain seek care is difficulty performing everyday functional activities.

  • Motor skill training is a novel approach that directly addresses the performance of painful and limited functional activities through challenging practice to improve performance and decrease pain.

Acknowledgments

Funding

This work was supported by the National Institutes of Health; National Institute of Child Health and Human Development, National Center for Medical Rehabilitation Research, grant number [R01 HD047709].

Footnotes

Disclosure statement

The authors report no other declarations of interest.

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