Effectiveness of motor control exercise combined with manual therapy in patients with low back pain classified in directional patterns of instability

There are 5 subgroups (directional patterns of instability), within motor control impairment group, These are: flexion, flexion/lateral shifting, active extension, pasive extension and multidirectional patterns. We will focus only in flexor pattern. First, Directional pattern will be evaluated with 4 specific functional motor control tests to both groups for flexion pattern, Only flexion patterns will be selected for our study. Then, patients will be divided in intervention and control groups. Experimental group will perform a specific exercise for their flexion pattern of lumbar instability. Exercises will be controlled movements where they will activate Multifidus, Psoas Major, spinal erectors muscles, and we will instruct that these exercises will be done with slowness and attention. Exercises examples for flexion pattern are: - In supine position; Anterior pelvic tilt; hip flexion maintening neutral lordosis of low back. - In sit position: anterior bend of trunk keeping neutral lordisis of low back - In quadruped position: hips double flexion towards heels keeping neutral lordosis of low back. - To do Squats, maintening neutral lordosis Exercises examples for extension pattern are (this exercises are only an explication for contrary pattern, futhermore these exercises are out of protocol, it is for show the difference): -Posterior pelvic tilt in supine position with 45 degrees flexion hip and 45 degrees flexion knee . -In supine position, with 45 degrees flexion hip and 45 degrees flexion knee; to flex hip to 90 degrees without separate lumbar segment of ground (neutral lordosis of low back). One example for passive extension, (these exercises are out of protocol); -In sedestation position, to perform a hip flexion, tilting the trunk forward without losing lordosis of low back. We will be 3 physiotherapists that will be in normal rehabilitation service working with patients, one by one. Patients will be 2 weeks (5 sessions/week; 45 minutes/ session) doing the supervised exercises at hospital and then, they will continue exercises at home during one month more (5 session/ week) at least. Home exercises will be same that performed at hospital, with equal duration. Adherence will not be assessed; we will say to patient the recomendation to continue exercise at least one month more with same frecuency.