The effectiveness of walking versus exercise on pain and function in chronic low back pain: a systematic review and meta-analysis of randomized trials

Motivation toward physical activity in patients with chronic musculoskeletal disorders: a meta-analysis of the efficacy of behavioural interventions

Musculoskeletal disorders (MDs) represent a global health issue, which can lead to disability. Physical activity (PA) reduces pain and increases physical function among patients with MDs. To promote behavioural changes, it seems important to focus on modifiable factors, such as motivation. Thus, this review aims to assess effects of interventions targeting PA on motivation towards PA. Searches used terms referring to "physical activity", "motivation" and "chronic musculoskeletal disorders" on the databases PubMed, PsychINFO, MEDLINE, EMBASE, PEDro and Web of Science. All types of intervention-including but not limited to RCTs-were eligible for inclusion. Risk of bias was assessed with the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). Among 6 489 abstracts identified, there were 387 eligible studies and 19 were included, reporting in total 34 effect sizes. The meta-analysis concerned 1 869 patients and indicated a small effect of interventions on change in motivation towards PA (d = 0.34; 95% CI [0.15; 0.54]; p < .01; k = 33). Behavioural interventions positively impact PA motivation in patients with MDs. In the literature, most studies focused on intervention's effect on fear of movement. Future research should assess other explicit motivational constructs, as well as implicit processes.

The Impact of Pain on Mobility in Patients with Cancer

OBJECTIVES

Provide an overview of how pain impacts mobility in patients with cancer.

METHODS

A literature search was conducted in PubMed and on Google Scholar using search terms, cancer pain with mobility, acute and chronic pain syndromes, enhanced recovery after surgery, nursing care, and rehabilitation. Peer-reviewed research studies, review articles, and pain guidelines and position papers were reviewed to provide an overview on cancer pain, its impact on mobility, and the nurse's role in managing pain and optimizing mobility and functional outcomes.

RESULTS

Firty-two references were included in this overview. This body of literature is replete with studies on the management of pain; however, the tie between pain and mobility has not been well described aside from the breakthrough pain literature. This manuscript weaves these two important concepts together to better inform nurses and other clinicians regarding the importance of managing pain to even begin mobilizing patients, especially following surgery and for other painful conditions.

CONCLUSIONS

Oncology nurses play an integral role in assessing and managing cancer pain. It is important for nurses to recognize how their pain management interventions lead to improved mobility and functioning in patients with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Nurses comprise the largest workforce around the globe and are well-equipped to assess and manage cancer pain in all cancer care settings. As leaders within the healthcare team, making recommendations to better control pain and communicating with other team members regarding the pain plan is essential in improving mobility in patients with cancer.

Promoting running as the best treatment for lower back pain in physiotherapy practice: a best practice implementation project

OBJECTIVES

This project aimed to promote running as the best treatment for lower back pain (LBP) in an outpatient setting.

INTRODUCTION

LBP is one of the most prevalent conditions worldwide. Sixty-two percent of all Germans experience episodes of non-specific back pain at least once a year, with one-fifth developing chronic conditions. Intervertebral disc (IVD) degeneration is a natural process, contributing to periods of acute LBP. However, the scientific literature and guidelines partially overlook the significance of water management in IVD. This implementation project sought to address this gap by educating patients about this process. Running and/or walking were chosen as general approaches for treatment rather than specific disease-related approaches.

METHODS

This implementation project was conducted in an outpatient physiotherapy clinic in Brandenburg, Germany, utilizing the JBI Evidence Implementation Framework. An evidence-informed clinical audit and feedback strategy was used to measure compliance with ten audit criteria. Five physiotherapists and 20 patients took part in the audits.

RESULTS

At baseline, only 20% of participating physiotherapists screened for yellow flags regarding psychological issues. However, after project implementation, this criterion scored 100% compliance. Some patients performed exercises independently, but confusion persisted regarding the choice of beneficial exercises. Patients continued running, but those who took a break due to pain expressed uncertainty about resuming.

CONCLUSIONS

The project highlighted the effectiveness of collaborative efforts between patients and therapists to address the issue. The project team's conviction in action and solution strategies serves as the foundation for this collaboration. This implementation strategy provided "running" patients with the confidence to either resume or reintegrate running after an extended break.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A222.

A Mind-Body Intervention to Improve Physical Activity for Patients with Chronic Hip-Related Pain: Protocol for a Mixed Methods Study

BACKGROUND

Pain and dysfunction persist for most patients following hip-related pain treatment. Additionally, individuals with hip-related pain are typically less physically active than individuals without hip pain, despite evidence that regular physical activity reduces chronic musculoskeletal pain. Poor psychological health is common in patients with hip-related pain and further reinforces low physical activity. Mind-body interventions can improve psychological health and activity levels but have yet to be integrated to provide comprehensive, psychologically informed care for patients with hip-related pain. Thus, we are using the NCCIH intervention development framework to develop Helping Improve PSychological Health (HIPS), a novel, multimodal mind-body intervention to improve physical activity for individuals with hip-related pain and poor psychological health.

METHODS

We will recruit physical therapists (N = 20) and patients with hip-related pain (N = 20) to participate in 60 min qualitative interviews (focus groups with therapists; one-on-one interviews with patients). Using these data, we will develop the initial HIPS intervention and provider training materials. One physical therapist will be trained to deliver the HIPS intervention to five participants in an open pilot trial. Participants will attend six 30 min HIPS intervention sessions. We will collect quantitative data on satisfaction, improvement, and physical activity, alongside qualitative exit interviews with participants and the physical therapist in order to refine the HIPS intervention and provider training materials.

RESULTS

This study has been approved by the MGB IRB. We aim to develop and test the initial feasibility of the HIPS intervention in an open pilot trial. The findings from this project will inform a subsequent feasibility RCT.

Physical activity should be the primary intervention for individuals living with chronic pain A position paper from the European Pain Federation (EFIC) 'On the Move' Task Force

BACKGROUND

There is clear evidence demonstrating the benefits of physical activity (PA) on pain and overall health, however, PA is challenging for many individuals living with chronic pain. Even non-exercise specialists can (cost) effectively promote PA, but many health professionals report a number of barriers in providing guidance on PA, suggesting that it is not consistently promoted. This expert position paper summarizes the evidence and provides five recommendations for health professionals to assess, advise and support individuals living with any chronic pain condition with a long life expectancy in adopting and sustaining physically active lifestyles.

METHODS

This position paper was prepared by the 'On The Move' Task Force of the European Pain Federation EFIC. Final recommendations were endorsed by the European Pain Forum, Pain Alliance Europe and the Executive Board of EFIC.

RESULTS

We recommend that all health professionals (1) Take a history of the persons' PA levels, and put PA on the agenda, (2) Advise that PA is important and safe for individuals living with chronic pain, (3) Deliver a brief PA intervention and support individuals living with chronic pain in becoming physically active, (4) Discuss acceptable levels of PA-related soreness and pain and (5) Provide ongoing support in staying physically active.

SIGNIFICANCE

Physical activity is safe and offers several advantages, including general health benefits, low risk of side effects, low cost and not requiring access to healthcare. Adoption of these recommendations can improve the quality of care and life of individuals living with chronic pain and reduce their overall health risks.

"Finding a new normal: the lived experience of persons' journey towards coping with persistent low back pain"

INTRODUCTION

Persistent low back pain (PLBP) is the biggest global cause of disability. Persons with PLBP experience biographic disruption and existential crisis. Guidelines recommend a biopsychosocial approach to management, with the emphasis on coping strategies.

PURPOSE

However, there is a paucity of research exploring the lived experience of persons who self-identify as coping with PLBP.

METHOD

The study used an interpretive phenomenological approach, analyzing transcripts from 1:1 interviews with six persons who self-identify as coping with PLBP. Poetic language was used to elicit empathic, embodied relational understanding and convey a richer understanding of the phenomenon that authentic quotations might not able to reveal.

FINDINGS AND CONCLUSION

Participants' descriptions conveyed the sense of a journey, starting with the loss of a sense of self as they engaged in the pain battle, followed by a transition toward a new 'normal,' in which time, acceptance and trust in their own intuition were meaningful components. Although anxiety and fear were a continued presence, but they became more manageable. Society's role in the coping process was significantly meaningful and is something which requires reflections from therapists' and more widely.

Improving multimodal physical function in adults with heterogeneous chronic pain; Protocol for a multisite feasibility RCT

BACKGROUND

Chronic pain is associated with substantial impairment in physical function, which has been identified as a top concern among persons with pain. GetActive-Fitbit, a mind-body activity program, is feasible, acceptable, and associated with improvement in physical function among primarily White, sedentary individuals with pain. In preparation for a multisite efficacy trial, we must examine feasibility across multiple sites with diverse patient populations. Here we describe the protocol of a multisite, feasibility RCT comparing GetActive-Fitbit with a time- and attention-matched educational comparison (Healthy Living for Pain). We aim to 1) test multisite fidelity of clinician training; 2) evaluate multisite feasibility benchmarks, including recruitment of chronic pain patients taking <5000 steps/day and racial and ethnic minorities; and 3) optimize fidelity and study protocol in preparation for a future multisite efficacy trial.

METHODS

Clinician training fidelity was assessed via roleplays and mock group sessions. Feasibility (i.e., recruitment, acceptability, credibility, adherence, satisfaction), multimodal physical function (e.g., self-report, 6-Minute Walk Test, step-count), and other psychosocial outcomes are assessed at baseline, posttest, and 6 months. Protocol optimization will be assessed using exit interviews and cross-site meetings.

RESULTS

The trial is ongoing. Clinician training is complete. 87 participants have been recruited. 54 completed baseline assessments and randomization, 44 are mid-intervention, and 9 have completed the intervention and posttest.

CONCLUSIONS

This study addresses the critical need for feasible, acceptable mind-body-activity interventions for chronic pain that follow evidence-based guidelines and improve all aspects of physical function across diverse populations. Results will inform a future fully-powered multisite efficacy trial.

CLINICAL TRIAL REGISTRATION

NCT05700383.

Water-Based Exercise in Patients With Nonspecific Chronic Low-Back Pain: A Systematic Review With Meta-Analysis

ABSTRACT

Babiloni-Lopez, C, Fritz, N, Ramirez-Campillo, R, and Colado, JC. Water-based exercise in patients with nonspecific chronic low-back pain: a systematic review with meta-analysis. J Strength Cond Res 38(1): 206-219, 2024-This study aimed to systematically review and synthesize evidence (i.e., active [land-based training] and nonactive controls [e.g., receiving usual care]) regarding the effects of water-based training on patients with nonspecific chronic low-back pain (NSCLBP). Web of Science (WOS), PubMed (MEDLINE), EMBASE, EBSCO (SPORTDiscus; CINAHL), and PEDro were searched, with no date restrictions, until October 2021. The included studies satisfied the following criteria: (a) NSCLBP (≥12 weeks) patients, (b) water-based intervention, (c) control group (land-based trained; nonactive group), and (d) outcomes related to pain, disability, quality of life, or flexibility. The main outcome analyzed in the meta-analysis was pain intensity. Secondary outcomes included disability, body mass index, and flexibility. The random-effects model was used, and effect size (ES) values are presented with 95% confidence intervals (CIs). The impact of heterogeneity was assessed (I2 statistic), with values of <25%, 25-75%, and >75% representing low, moderate, and high levels, respectively. Alpha was set at p < 0.05. In conclusion, 15 studies (n = 524) were meta-analyzed. After intervention, pain intensity was reduced compared with nonactive controls (ES = -3.61; p < 0.001) and a similar reduction was noted when compared with land-based trained group (ES = -0.14; p = 0.359). Greater decrease in disability (ES = 2.15; p < 0.001) and greater increase in sit-and-reach (i.e., flexibility; ES = -2.44; p < 0.001) were noted after intervention compared with the nonactive group. In conclusion, water-based exercise therapy reduces pain intensity, disability, and increases flexibility in NSCLBP compared with nonactive subjects and was equally effective compared with land-based exercise to reduce pain. Favorable effects may be expected at ≤8 weeks. However, due to several methodological issues (e.g., high heterogeneity), for the improvement of most outcomes, we are unable to provide other than a weak recommendation in favor of intervention compared with control treatment.

Sexual Disability in Low Back Pain: Diagnostic and Therapeutic Framework for Physical Therapists

BACKGROUND

The literature shows a relationship between sexual activity and low back pain (LBP). The aim of this work is to provide a theoretical framework and practical proposal for the management of sexual disability in individuals with LBP.

METHODS

Based on a literature review, a team of specialized physical therapists developed a pattern for the management of LBP-related sexual disability.

RESULTS

A patient reporting LBP-related sexual disability may be included in one of four clinical decision-making pathways corresponding to one of the following: #1 standard physical therapy (PT); #2 psychologically informed physical therapy (PIPT); #3 PIPT with referral; or #4 immediate referral. Standard PT concerns the management of LBP-related sexual disability in the absence of psychosocial or pathological issues. It includes strategies for pain modulation, stiffness management, motor control, stabilization, functional training, pacing activities comprising education, and stay-active advice. PIPT refers to patients with yellow flags or concerns about their relationship with partners; this treatment is oriented towards a specific psychological approach. "PIPT with referral" and "Immediate referral" pathways concern patients needing to be referred to specialists in other fields due to relationship problems or conditions requiring medical management or pelvic floor or sexual rehabilitation.

CONCLUSIONS

The proposed framework can help clinicians properly manage patients with LBP-related sexual disability.

Association of meeting 24-hour movement guidelines with low back pain among adults

Background

According to recently published 24-hour movement guidelines, adults should spend: ≥150 minutes/week in moderate-to-vigorous physical activity (MVPA); <8 hours/day in sedentary behaviour (SB); and 7-9 hours/day sleeping.

Objective

We explored the association between meeting these recommendations and low back pain (LBP)-the most common musculoskeletal disorder.

Methods

We collected self-reported data from 2333 adults about: MVPA, SB and sleep duration; frequency and intensity of LBP; and sociodemographic and lifestyle characteristics.

Results

Meeting a combination of SB and sleep recommendations was associated with lower odds of LBP in the past week and past month (adjusted odds ratio [OR]: 0.64 and 0.52, respectively; p < 0.05 for both). Among LBP sufferers, meeting any combination of recommendations that includes sleep was associated with lower odds of frequent (OR range: 0.49-0.61; p < 0.05 for all) and intense (OR range: 0.39-0.66; p < 0.05 for all) LBP in the past week, while meeting a combination of SB and sleep recommendations or all three recommendations was associated with lower odds of intense LBP in the past month and past year (OR range: 0.50-0.68; p < 0.05 for all). The likelihood of experiencing higher frequency and intensity of LBP decreased with the number of recommendations met (p for linear trend < 0.05).

Conclusion

Meeting the SB and sleep recommendations in combination is associated with a lower likelihood of LBP, while adhering to the overall 24-hour movement guidelines or any combination of recommendations that includes sleep is associated with lower frequency and intensity of LBP among LBP sufferers.

Low Back Pain in Resident Doctors with Standardized Training in China: A Cross-Sectional Study

Background

Low back pain (LBP) is a prevalent occupational disease with high morbidity among healthcare workers. Since the implementation of standardized residency training in China in 2015, the training intensity has significantly increased, which may lead to a higher incidence of LBP. However, epidemiological studies on LBP among resident doctors with standardized training remain scarce.

Objective

To investigate the prevalence and associated factors of LBP among resident doctors with standardized training in a tertiary hospital in China.

Methods

A cross-sectional study was conducted using self-administered questionnaires to collect information on demographics, lifestyle factors, work-related factors, and LBP from 345 resident doctors. Descriptive statistics were used to analyze the prevalence of LBP. Logistic regression analysis was performed to identify factors associated with LBP.

Results

Among 345 participants, the 1-year prevalence of LBP was 75.9%. Multivariable analysis revealed that physical exercise, weekly working hours, and prolonged sitting were independent risk factors for LBP.

Conclusion

The prevalence of LBP among resident doctors was high. Promoting physical exercise, controlling working hours, and improving sitting posture may help prevent LBP. The study was limited by its cross-sectional design and self-reported data. Future studies should use longitudinal designs, objective measures, and larger and more representative samples to further explore the epidemiology and etiology of LBP among resident doctors with standardized training.

The effectiveness of different aerobic exercises to improve pain intensity and disability in chronic low back pain patients: a systematic review

Background: Physical activity, including aerobic exercise, is highly recommended for chronic low back pain (CLBP) patients to improve pain intensity and functional disability. Objectives: To assess the effectiveness of different aerobic exercises to reduce pain intensity and functional disability in patients with CLBP. Methods: A computer-aided search was performed to find Randomised Controlled Trials (RCTs) that evaluated the effectiveness of different aerobic exercises in CLBP. Articles published between January 2007 to December 2020 were included in the review. Quality assessment using the PEDro scale, extraction of relevant information, and evaluation of outcomes were done by two reviewers independently. Results: A total of 17 studies were included that involved 1146 participants. Outcomes suggested that aerobic exercise combined with other interventions was more effective than aerobic exercise alone. Aerobic exercise with higher frequency (≥ 5 days/week) and longer duration (≥ 12 weeks) were effective to gain clinically significant (≥ 30%) improvements. Environment and using pedometer did not seem to influence the outcomes. Conclusions: Pain intensity and functional disability in CLBP patients can be minimized by prescribing aerobic exercise. However, to get better improvements, aerobic exercise should be done in combination with other interventions and at optimum frequency and duration. Further studies should emphasize examining the optimal doses and duration of different aerobic exercises.

Exercise Therapy in Nonspecific Low Back Pain among Individuals with Lower-Limb Amputation: A Systematic Review

Low back pain is very common condition that often becomes a long-lasting problem in prostheses users after lower limb amputation. The presented study aims to decide the potential benefits of exercise therapy on low back pain among lower limb amputees by using a systematic review. The PICO technique was used to answer the primary issue of this review: Does exercise treatment lessen the prevalence of low back pain in the population of lower limb amputees? Systematic review was conducted in the following databases: Medline-PubMed, EMBASE, Scopus, and Web of Science. Studies up to September 2010 published in English are included. Aim, target population, development and execution strategies, and treatment suggestions were among the data gathered. The primary outcomes of interest were exercise interventions as a therapy for low back pain but only two articles met including criteria. The search was broadened and 21 studies describing biomechanical changes in gait and pelvic-spine posture were analysed. This review indicates that movement therapy is a potential treatment strategy in low back pain among amputees. The major limitation of the study is the very heterogenous group of subjects in terms of amputation level, baseline activity level and comorbidities. We used a procedure that was registered in PROSPERO (CRD42022345556) to perform this systematic review of systematic reviews. There is a necessity of good quality research for concluding a consensus of exercise intervention.

The effect of exercise on health-related quality of life in persons with musculoskeletal pain: A meta-analysis of randomised control trials

OBJECTIVES

Exercise has positive effects on musculoskeletal pain. In this project, the impact of exercise was studied on improving health-related quality of life in persons with musculoskeletal pain.

METHOD

The study design was a systematic review and meta-analysis. A search was conducted to find original studies in four sources, including PubMed, Web of Science, the Cochrane Library and Scopus, and this search was limited to the original articles published until April 2021, which were in English. For each study, the effect size was calculated. The analysis was based on the random-effects method.

RESULT

Twenty-Seven randomised control trial studies were included in the meta-analysis. The total population of participants in the meta-analysis was 1927 persons. Exercise improves health-related quality of life in these persons and the hedges' g was 0.66 (95% CI = 0.38-0.94; I²  = 88.29%).

DISCUSSION

Overall, based on the findings, exercise is associated with improving the health-related quality of life of persons with musculoskeletal pain, and therefore the health implications of this finding are beneficial to the general population and professionals.

What Modifies the Effect of an Exercise Treatment for Chronic Low Back Pain? A Meta-epidemiologic Regression Analysis of Risk of Bias and Comparative Effectiveness

OBJECTIVE: To investigate how risk of bias and intervention type modify effect sizes of exercise interventions that are intended to reduce chronic low back pain intensity. DESIGN: Systematic review with meta-epidemiologic regression analysis. LITERATURE SEARCH: PubMed, CENTRAL, Embase, and CINAHL (until January 31, 2021). STUDY SELECTION CRITERIA: Systematic reviews with meta-analyses of randomized controlled exercise trials. DATA SYNTHESIS: The dependent variable was pain, calculated as standardized mean difference (SMD). Potential effect modifiers were risk of bias, exercise modes, study, and meta-analyses characteristics. Multilevel meta-regressions and inverse variance-weighted meta-regressions with random intercepts were modelled. RESULTS: Data from 26 systematic reviews (k = 349 effect sizes, n = 18,879 participants) were analysed. The overall mean effect was SMD: -0.35 (k = 349, [95% CI -0.02 to -0.7]). There was a clinically relevant effect overestimation in studies with a high risk of bias due to missing outcomes (each k = 197, Beta coefficient = -1.9 [95% CI -2.9 to -.9]) and low sample size (B = 0.01 [.001 to .01], [ie, one participant more leads to an SMD decrease of 0.01]). There was a clinically relevant underestimation of the effect when studies were at high risk of bias in allocation concealment (B = 1.3 [.5 to 2.1]) and outcome measurement (B = 1.3 [.44 to 2.0]). Motor control and stabilization training (B = -1.3 [-2.3 to -.37]) had the largest effects; stretching (B = 1.3 [-.03 to .5]) had the smallest effect. CONCLUSIONS: The effects of exercise trials at high risk of bias may be overestimated or underestimated. After accounting for risk of bias, motor control and stabilization exercises may represent the most effective exercise therapies for chronic low back pain. J Orthop Sports Phys Ther 2022;52(12):792-802. Epub: 12 August 2022. doi:10.2519/jospt.2022.11149.

Results of ELBRUS clinical non-interventional study

Objective: non-interventional study ELBRUS (Etoricoxib in the Treatment of Back Pain) was conducted to investigate the efficacy and safety of daily administration of Rixia® (Etoricoxib) 60 mg per day in patients with chronic non-specific low back pain (CNSLBP).

Patients and methods. The study included 50 patients (31 women and 19 men, mean age 54.3±16.8 years) with CNSLBP. Educational conversation, cognitive therapy, regular therapeutic exercises, identification and treatment of comorbidities were conducted. Patients received etoricoxib 60 mg once daily. Pain intensity was assessed on a 10-point numerical rating scale (NRS), pain-related disability was assessed on the Oswestry Scale (ODS), and emotional state was assessed on the Hospital Anxiety and Depression Scale (HADS).

Results and discussion. The causes of CNSLBP were: in 5 (10%) patients – sacroiliac joint involvement, in 14 (28%) – lower lumbar facet joints involvement, in 3 (6%) – myofascial pain, the remaining 28 (56%) patients had a combination of several reasons. As a result of complex treatment, the intensity of pain at rest decreased on average from 4.0±2.5 to 1.4±1.3 points, while moving – from 6.6±1.9 to 2.8±1.8 points, at night – from 2.7±2 to 0.7±0.9 points according to the NRS, disability – from 39±18.9 to 19.9±14.6% according to the ODS, the severity of anxiety – from 6.5±3.9 to 3.3±2.4 points and depression from 5.0±3.7 to 3.1±2.9 points according to HADS (p<0.001). The duration of treatment was 14.14±3.6 days on average. No adverse events were observed during treatment with etoricoxib. Conclusion. The efficacy and safety of etoricoxib in the complex therapy of patients with CNSLBP was noted. Keywords: chronic nonspecific low back pain, non-steroidal anti-inflammatory drugs, etoricoxib, Rixia®>˂0.001). The duration of treatment was 14.14±3.6 days on average. No adverse events were observed during treatment with etoricoxib.

Conclusion. The efficacy and safety of etoricoxib in the complex therapy of patients with CNSLBP was noted. 

Summarizing the effects of different exercise types in chronic low back pain - a systematic review of systematic reviews

Background

In chronic LBP (CLBP), guideline-endorsed treatment is to stay active, return to normal activity, and to exercise. Several reviews on various exercise types used in CLBP have been published. We aimed to identify systematic reviews of common exercise types used in CLBP, to appraise their quality, and to summarize and compare their effect on pain and disability.

Methods

We searched the databases OVID MEDLINE, EMBASE, COCHRANE LIBRARY, and WEB OF SCIENCE (Core collection) for systematic reviews and meta-analyses on adults between 18 and 70 years of age suffering from chronic or recurrent LBP for a period of at least 12 weeks, which investigated the effects of exercises on pain and disability. All searches were conducted without language restriction. The search was performed up until 2022–01-26. The included reviews were grouped into nine exercise types: aerobic training, aquatic exercises, motor control exercises (MCE), resistance training, Pilates, sling exercises, traditional Chinese exercises (TCE), walking, and yoga. The study quality was assessed with AMSTAR-2. For each exercise type, a narrative analysis was performed, and the level of evidence for the effects of exercise was assessed through GRADE.

Results

Our database search resulted in 3,475 systematic reviews. Out of the 253 full texts that were screened, we included 45 systematic reviews and meta-analyses. The quality of the included reviews ranged from high to critically low. Due to large heterogeneity, no meta-analyses were performed. We found low-to-moderate evidence of mainly short-term and small beneficial effects on pain and disability for MCE, Pilates, resistance training, TCE, and yoga compared to no or minimal intervention.

Conclusions

Our findings show that the effect of various exercise types used in CLBP on pain and disability varies with no major difference between exercise types. Many of the included systematic reviews were of low-to-moderate quality and based on randomized controlled trials with high risk of bias. The conflicting results seen, undermine the certainty of the results leading to very-low-to-moderate quality of evidence for our results. Future systematic reviews should be of higher quality to minimize waste of resources.

Trial registration

PROSPERO: Reg no 190409 Registration date 01AUG 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05722-x.

The Role of Exercise in Treating Low Back Pain

ABSTRACT

The purpose of this review is to highlight the role of exercise in preventing and managing acute and chronic axial low back pain (LBP). LBP is one of the leading contributors to years lived with disability as well as health care expenditures in the United States. With an expected increase in prevalence due to an aging population, sports medicine providers have a unique opportunity to provide effective treatment strategies incorporating exercise advice and prescription. Although the majority of individuals with acute LBP will have their symptoms resolve spontaneously, almost 40% will have recurrence or develop chronic LBP within 1 year. No single exercise method has been shown to be more effective than another. The evidence for walking programs, aerobic exercise, yoga, Pilates, and tai chi for LBP is discussed. Our review summarizes the beneficial role of a personalized exercise program and related counseling strategies in the prevention and management of LBP.

Maximal aerobic capacity is associated with lifting capacity, but not with self-reported functioning measures in patients with primary chronic low back pain: a cross-sectional study

Objective

Maximal exercise testing is considered the gold standard to assess V̇O₂max. However, maximal exercise testing was previously deemed unfeasible and unsafe in chronic low back pain (CLBP) patients. Consequently, most previous studies on aerobic capacity and functioning in patients with CLBP were performed with submaximal testing protocols. A recent study demonstrated the safety, feasibility and tolerance of maximal exercise testing in patients with CLBP. Therefore, the relation between aerobic capacity and functioning should be reevaluated. This cross-sectional study aims to determine the relationship between maximal aerobic capacity and four measures of functioning: lifting capacity, work ability, pain-related disability and physical functioning in patients with CLBP.

Methods

The maximal aerobic capacity of patients with CLBP was assessed with a maximal cardiopulmonary exercise test. Functioning was measured with a floor-to-waist lifting capacity test and three questionnaires: Work Ability Score, Pain Disability Index and Physical Functioning subscale of RAND-36. The associations between maximal aerobic capacity and each of the functioning measures were analysed with multiple linear regression analyses while controlling for potential confounders.

Results

Data of n=74 patients with CLBP were analysed. After controlling for potential confounders, maximal aerobic capacity was moderately associated with lifting capacity (β=0.32, p=0.006), but not with any of the other functioning measures (β=−0.08 to 0.12, p>0.288).

Conclusion

A higher level of maximal aerobic capacity is moderately associated with a higher lifting capacity, but not with self-reported work ability, pain-related disability and physical functioning.

Is it possible to discriminate workers with a higher prevalence of low back pain considering daily exposure time in a work-related lumbar posture? A diagnostic accuracy study

The study aimed to develop and validate a cut-off for daily postures to discriminate workers with low back pain. The self-reported episode of low back pain in the last year and during the previous week and the total spent time in occupational postures of 529 workers were used to screen workers who more likely would report low back pain. The receiver operating characteristics curve verified the ability of daily time in each posture in discriminating workers with low back pain in a training sample. Then, the chi-squared test and measurements of the diagnostic accuracy were performed in the testing sample. The daily time spent in a given posture was not able to accurately discriminate against workers with low back pain. Total time spent walking was the only daily posture that discriminated workers with low back pain in the last year in the testing sample, albeit with low accuracy. Practitioner Summary: The daily time spent in a given posture was not able to accurately distinguish workers with low back pain. Total spent time in walking presented modest diagnostic accuracy and should be interpreted cautiously. The spent time in a particular posture did not detect workers with LBP in the last week.

Associations of walking and resistance training with chronic low back pain in older adults: A cross-sectional analysis of Korean National Health and Nutrition Examination Survey data

ABSTRACT

Physical activities, such as resistance training and walking, are known to be effective against chronic low back pain (CLBP). However, few studies have examined the associations of walking and resistance training with CLBP in the general older population. Therefore, this study analyzed these relationships in the older Korean population (aged ≥65 years), with the goal of determining which exercise is better for CLBP.This cross-sectional study analyzed Korean National Health and Nutrition Examination Survey data for the period 2012 to 2015. The Korean National Health and Nutrition Examination Survey, which provides representative data for the Korean population, uses a clustered, multistage, random sampling method with stratification based on geographic area, age, and sex. Three multiple logistic regression models were generated in this study to determine the associations of walking and resistance training with CLBP.A total of 5233 participants were enrolled, 3641 (69.6%) of whom were free from CLBP; the remaining 1592 (30.4%) had CLBP. 78.4% and 64.8% of the non-CLBP and CLBP group patients, respectively, walked at least once a week. Also, 23.5% and 11.6% of the participants in the non-CLBP and CLBP groups, respectively, engaged in resistance training at least once a week. In the multiple logistic regression analysis, which was adjusted for all potential confounders, walking was significantly associated with a lower risk of CLBP (1-2d/wk: odds ratio [OR] = 0.65, P = .002; 3-4d/wk: OR = 0.69, P = .004; ≥5 d/wk: OR = 0.57, P < .001). However, resistance training showed no association with the risk of CLBP.In this cross-sectional study, walking was associated with a lower risk of CLBP. In particular, walking >5days per week had the maximum benefit in a lower risk of CLBP. Therefore, clinicians can consider recommending walking to patients with CLBP for optimal pain improvement.

Walking, Cycling, and Swimming for Nonspecific Low Back Pain: A Systematic Review With Meta-analysis

OBJECTIVE

To investigate the effectiveness of walking/running, cycling, or swimming for treating or preventing nonspecific low back pain (LBP).

DESIGN

Intervention systematic review.

LITERATURE SEARCH

Five databases were searched to April 2021.

STUDY SELECTION CRITERIA

Randomized controlled trials evaluating walking/running, cycling, or swimming to treat or prevent LBP were included.

DATA SYNTHESIS

We calculated standardized mean differences (SMDs) and 95% confidence intervals (CIs). Certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

No trials assessed LBP prevention or addressed acute LBP. Nineteen trials (2362 participants) assessed treatment of chronic/recurrent LBP. Low-certainty evidence suggests that walking/running was less effective than alternate interventions in reducing pain in the short term (8 trials; SMD, 0.81; 95% CI: 0.28, 1.34) and medium term (5 trials; SMD, 0.80; 95% CI: 0.10, 1.49). High-certainty evidence suggests that walking/running was less effective than alternate interventions at reducing disability in the short term (8 trials; SMD, 0.22; 95% CI: 0.06, 0.38) and medium term (4 trials; SMD, 0.28; 95% CI: 0.05, 0.51). There was high-certainty evidence of a small effect in favor of walking/running compared to minimal/no intervention for reducing pain in the short term (10 trials; SMD, -0.23; 95% CI: -0.35, -0.10) and medium term (6 trials; SMD, -0.26; 95% CI: -0.40, -0.13) and disability in the short term (7 trials; SMD, -0.19; 95% CI: -0.33, -0.06). Scarcity of trials meant few conclusions could be drawn regarding cycling and swimming.

CONCLUSION

Although less effective than alternate interventions, walking/running was slightly more effective than minimal/no intervention for treating chronic/recurrent LBP. J Orthop Sports Phys Ther 2022;52(2):85-99. Epub 16 Nov 2021. doi:10.2519/jospt.2022.10612.

COVID-19 and urban planning: Built environment, health, and well-being in Greek cities before and during the pandemic

The coronavirus disease (COVID-19) pandemic has led to dramatic changes in quality of life, bringing to the forefront of the debate the question of planning and design of pandemic-resilient cities. Using quasi-longitudinal survey data (via a social media campaign) and geospatial data from Greek cities, we evaluate changes in health and well-being during COVID-19 compared to the pre-COVID-19 period, and then explore in detail how specific built environment characteristics in Athens and Thessaloniki relate to health and well-being before and during COVID-19. Results suggest that overall health, life satisfaction, happiness, personal relationships satisfaction, leisure satisfaction, satisfaction with income, and satisfaction with vacations all decreased during COVID-19, while anxiety and back pain increased during COVID-19. The role of the urban built environment in health and well-being was found to differ considerably for the COVID-19 period compared to pre-COVID-19. Proximity to large parks, proximity to numerous local facilities, lower neighborhood density, living further from the city center, and living in a larger dwelling were associated with better health and well-being outcomes during COVID-19. Urban planning and relevant policies that cities adopt should carefully focus on mitigating implications for critical issues such as the quest for sustainable urban development and city forms.

THE INFLUENCE OF PHYSICAL ACTIVITY ON THE PREVALENCE OF LOW BACK PAIN AMONG THE PORTUGUESE POPULATION

ABSTRACT Objective: I) To investigate the influence of physical activity (PA) on levels of low back pain, and II) To classify the respondents regarding low back pain. Methods: Collection of responses, through an online questionnaire, from 199 adults aged between 18 and 65 years (36.05 ± 11.90 years). The following inclusion criteria were applied: I) Suffering or have suffered pain in the spine at some point in life; and as an exclusion criterion: I) Being outside the required age range. Results: Investigating the level of pain and the risk of low back pain, there was a significant association (r = 0.481; p≤0.01) between these two factors, indicating that the higher the levels of pain, the higher the risk of low back pain. Those who presented higher levels of chronic pain either did not practice any physical activity (58.8%), or practiced formal PA (42.9%) or practiced informal PA (30.7%). Those who had practiced physical exercise for three months or more mostly did not have chronic pain (70.1%). Conclusions: There was a decrease in chronic low back pain which was associated with increased time and frequency of PA, as well as the practice of postural physical exercises. Level of Evidence I; Prognostic Studies— Investigating the Effect of a Patient Characteristic on the Outcome of Disease.

Effectiveness of peloid therapy in patients with chronic low back pain: a single-blind controlled study

The aim of this study was to compare peloid therapy in addition to home exercise with home exercise alone in terms of pain, function, quality of life, and depression in patients with chronic low back pain (cLBP). A total of 106 cLBP patients were divided into two equal groups as treatment and control. The peloid therapy group had peloid therapy (with a total of 15 sessions on 5 days per week for 3 weeks duration with 45 °C temperature lasting 30 min/day) + home exercise program. The control group was only given a home exercise program. Patients completed the visual analog scale-pain (VAS-pain), patient and physician global assessments (VAS-PGA and VAS-PhGA), revised Oswestry disability index (rODI) for functional status, the short form-36 (SF-36) for quality of life, and Beck Depression Inventory (BDI) for depression three times as before treatment, after treatment (3rd week), and 1 month after the end of treatment. Assessments in the 3rd week at the end of treatment revealed statistically significant improvements for rODI (p = 0.013), VAS-pain (p = 0.039), and VAS-PhGA (p = 0.002) parameters in the peloid therapy group compared to the control group. Assessments in the 1st month after the end of treatment revealed statistically significant improvements in rODI (p < 0.001), VAS-pain (p < 0.001), VAS-PGA (p = 0.002), VAS-PhGA (p < 0.001), and SF-36VE (p = 0.022) parameters in the peloid therapy group compared to the control group. Peloid therapy + home exercise was statistically significantly superior to home exercise alone in improving pain and function in patients with cLBP. Peloid therapy may be recommended as a non-pharmacological treatment for cLBP patients. There is a need for randomized studies with longer follow-up including biochemical parameters to verify the beneficial effects observed in this study and elaborate the mechanisms of action.

Some types of exercise are more effective than others in people with chronic low back pain: a network meta-analysis

QUESTION

What are the effects of specific types of exercise treatments on pain intensity and functional limitation outcomes for adults with chronic low back pain?

DESIGN

Systematic review with network meta-analysis of randomised controlled trials.

PARTICIPANTS

Adults with non-specific low back pain for ≥ 12 weeks.

INTERVENTION

Exercise treatments prescribed or planned by a health professional that involved conducting specific activities, postures and/or movements with a goal to improve low back pain outcomes.

OUTCOME MEASURES

Pain intensity (eg, visual analogue scale or numerical rating scale) and back-related functional limitations (eg, Roland Morris Disability Questionnaire or Oswestry Disability Index), each standardised to range from 0 to 100.

RESULTS

This review included 217 randomised controlled trials with 20,969 participants and 507 treatment groups. Most exercise types were more effective than minimal treatment for pain and functional limitation outcomes. Network meta-analysis results were compatible with moderate to clinically important treatment effects for Pilates, McKenzie therapy, and functional restoration (pain only) and flexibility exercises (function only) compared with minimal treatment, other effective treatments and other exercise types. The estimated mean differences for these exercise types compared with minimal treatment ranged from -15 to -19 for pain and from -10 to -12 for functional limitation.

CONCLUSION

This review found evidence that Pilates, McKenzie therapy and functional restoration were more effective than other types of exercise treatment for reducing pain intensity and functional limitations. Nevertheless, people with chronic low back pain should be encouraged to perform the exercise that they enjoy to promote adherence.

REGISTRATION

DOI:10.1002/14651858.CD009790.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

HUMAN BODY’S HEALTH FUNCTION IMPROVEMENT BY VARIOUS WHOLE-BODY SPORTS EXERCISES

ABSTRACT Introduction Studies have shown that physical exercise is beneficial to people’s overall physical and mental health, but few research reports on the effects of different physical exercises on people’s human health. Object The paper explores the difference in human health function between people who adhere to traditional health sports and those who rarely exercise and provide a scientific basis for applying and promoting traditional health sports in TCM “prevention of disease”. Methods The paper surveyed 526 people who regularly participate in physical exercises and rarely exercise. The exercise items are divided into Tai Chi/Tai Chi sword group, Health Qigong Baduanjin group, Health Qigong Wuqinxi group, and Health Qigong Yijin group. Warp group, walking/jogging group. Results There are differences in the mental indicators of the people in different exercise groups. The overall average percentage levels of and NK cells in each exercise group and the tiny exercise group are different, and the difference is statistically significant (P<0.05). Conclusions Persisting in physical exercise is beneficial to the balance of health and function of the population. Level of evidence II; Therapeutic studies - investigation of treatment results.

Wearables-based walking program in addition to usual physiotherapy care for the management of patients with low back pain at medium or high risk of chronicity: A pilot randomized controlled trial

BACKGROUND

Although chronic low back pain (LBP) is a leading cause of disability and accounts for large costs, none of the available conventional treatments are clearly more favourable in treating people at increased risk of chronicity.

OBJECTIVES

To examine the feasibility and initial efficacy of a wearables-based walking intervention in addition to usual physiotherapy care in people with LBP at risk of chronicity.

METHODS

Twenty-six adult participants, diagnosed with non-specific LBP with medium or high risk of chronicity, were recruited from physiotherapy private practices. Participants were randomized into usual physiotherapy care (control, n = 14) and usual physiotherapy care plus a wearables-based walking intervention (experimental, n = 12). The intervention duration was 8 weeks. Feasibility outcomes included recruitment rate, adherence to the intervention, dropout rate, and serious adverse events reporting rate. Other outcomes included disability and pain (primary); and physical activity level, daily walking steps, depression, pain catastrophizing and fear of movement (secondary). The outcomes were assessed at baseline, post-intervention and 26 weeks post-randomization follow-up.

RESULTS

Adherence of experimental participants with the prescribed walking program was moderate. Four participants dropped out during the intervention, and no serious adverse events were reported. Participants in the experimental group showed significant improvement in pain at 26 weeks (β = -0.38; 95% confidence interval (CI) -0.66, -0.10; P = .013), compared with the control group. No between-group differences were found for disability at any time point and pain immediately post-intervention. Experimental participants demonstrated post-intervention improvement in light-intensity (β = 156.71; 95% CI 86.79, 226.64; P < .001), moderate-intensity physical activity (β = 0.46; 95% CI 0.12, 0.80; P = .012), and daily walking steps (β = 7099.13; 95% CI 4522.93, 9675.32; P < .001). Experimental participants demonstrated post-intervention increase in pain catastrophizing (β = 0.52, 95% CI 0.18, 0.86; P = .006). No between-group differences were found for pain catastrophizing at 26 weeks and other secondary outcomes.

CONCLUSION

Usual physiotherapy care plus a wearables-based walking intervention program was safe and moderately feasible, and provided significant reduction in pain at 26 weeks as well as increasing the total volume of light- and moderate-intensity physical activity, and daily walking steps immediately post-intervention.

Paravertebral intramuscular ozone therapy in lumbar disc hernia: A comprehensive retrospective study

BACKGROUND

Clinical studies assessing the impacts of ozone on the musculoskeletal framework are slowly expanding.

OBJECTIVE

In this study, we analyzed the impact of paravertebral ozone treatment (OT) injection treatment on distress and disability in patients with lumbar disc hernia (LDH).

METHODS

The records of 432 patients with L4-5 and L5-S1 LDH were examined retrospectively. 298 patients who met the inclusion criteria and who provided written informed consent were divided into two groups. Each group received 15 sets of physiotherapy at a rate of five sets every week (study group (n= 139), control group (n= 159)). Six OT injections were applied solely to the study group, two days per week. A visual pain score (VAS) was set up for distress and the Oswestry Disability Questionnaire (ODI) for disablement was administered when the groups were called to control before treatment, towards the end of the treatment, and three months after the treatment ended.

RESULTS

The groups had significantly reduced (p< 0.05) VAS and ODI scores following and three months after the treatment contrasted with their scores before the treatment. The Physiotherapy + OT group had significantly lower (p< 0.05) VAS and ODI scores than the physiotherapy group following and three months after the treatment.

CONCLUSIONS

Paravertebral OT injection is quite a safe and helpful treatment technique in LDH patients. Further studies should be conducted to investigate the long-term outcomes of the paravertebral OT application.

Integrated Meditation and Exercise Therapy: A Randomized Controlled Pilot of a Combined Nonpharmacological Intervention Focused on Reducing Disability and Pain in Patients with Chronic Low Back Pain

OBJECTIVE

This pilot trial examined the effects of a combined intervention of mindfulness meditation followed by aerobic walking exercise compared with a control condition in chronic low back pain patients. We hypothesized that meditation before exercise would reduce disability, pain, and anxiety by increasing mindfulness prior to physical activity compared with an audiobook control group.

PARTICIPANTS

Thirty-eight adults completed either meditation and exercise treatment (MedExT) (n=18) or an audiobook control condition (n=20).

SETTING

Duquesne University Exercise Physiology Laboratory.

DESIGN

A pilot, assessor-blinded, randomized controlled trial.

METHODS

Over a 4-week period, participants in the MedExT group performed 12-17 minutes of guided meditation followed by 30 minutes of moderate-intensity walking exercise 5 days per week. Measures of disability, pain, mindfulness, and anxiety were taken at baseline and postintervention. Pain perception measurements were taken daily.

RESULTS

Compared with the control group, we observed larger improvements in disability in the MedExT intervention, although the changes were modest and not statistically significant (mean between-group difference, -1.24; 95% confidence interval [CI], -3.1 to 0.6). For secondary outcome measures, MedExT increased mindfulness (within-group) from pre-intervention to postintervention (P=0.0141). Additionally, mean ratings of low back pain intensity and unpleasantness significantly improved with time for the MedExT group compared with that of the control group, respectively (intensity P=0.0008; unpleasantness P=0.0022).

CONCLUSION

. Overall, 4 weeks of MedExT produced suggestive between-group trends for disability, significant between-group differences for measures of pain, and significant within-group increases in mindfulness.

A randomized controlled trial investigating effects of an individualized pedometer driven walking program on chronic low back pain

BACKGROUND

Walking is an easily prescribed physical activity for people with low back pain (LBP). However, the evidence for its effectiveness to improve pain and disability levels for people with chronic low back pain (CLBP) within a community setting has not been evaluated. This study evaluates the effectiveness of a clinician guided, pedometer-driven, walking intervention for increasing physical activity and improving clinical outcomes compared to education and advice.

METHODS

Randomized controlled trial recruiting N = 174 adults with CLBP. Participants were randomly allocated into either a standardized care group (SG) or pedometer based walking group (WG) using minimization allocation with a 2:1 ratio to the WG. Prior to randomization all participants were given a standard package of education and advice regarding self-management and the benefits of staying active. Following randomization the WG undertook a physiotherapist guided pedometer-driven walking program for 12 weeks. This was individually tailored by weekly negotiation of daily step targets. Main outcome was the Oswestry Disability Index (ODI) recorded at baseline, 12 weeks, 6 and 12 months. Other outcomes included, numeric pain rating, International Physical Activity Questionnaire (IPAQ), Fear-Avoidance Beliefs Questionnaire (FABQ), Back Beliefs questionnaire (BBQ), Physical Activity Self-efficacy Scale, and EQ-5D-5L quality of life estimate.

RESULTS

N = 138 (79%) participants completed all outcome measures at 12 weeks reducing to N = 96 (55%) at 12 months. Both observed and intention to treat analysis did not show any statistically significant difference in ODI change score between the WG and the SG at all post-intervention time points. There were also no significant between group differences for change scores in all secondary outcome measures. Post hoc sensitivity analyses revealed moderately disabled participants (baseline ODI ≥ 21.0) demonstrated a greater reduction in mean ODI scores at 12 months in the WG compared to SG, while WG participants with a daily baseline step count < 7500 steps demonstrated a greater reduction in mean ODI scores at 12 weeks.

CONCLUSIONS

Overall, we found no significant difference in change of levels of (ODI) disability between the SG and WG following the walking intervention. However, ODI responses to a walking program for those with moderate levels of baseline disability and those with low baseline step count offer a potential future focus for continued research into the benefit of walking as a management strategy for chronic LBP.

TRIAL REGISTRATION

United States National Institutes of Health Clinical Trails registry (http://ClinicalTrials.gov/) No. NCT02284958 (27/10/2014).

Comparing the effects of aquatic exercises with or without high intensity on the functional status, muscular endurance, and performance of patients with chronic low back pain

BACKGROUND

The prevalence of low back pain is lower when physical fitness (aerobic and muscular) is higher. Strength exercises are important for subjects with low back pain, but there are few studies on the inclusion of aerobic exercise in low back pain programs. The aim of this study was to compare the effects of aquatic exercises with or without high-intensity component on the functional status, lumbar and abdominal muscle endurance, and performance of subjects with chronic low back pain.

METHODS

Forty-eight volunteers between 20 and 60 years old were randomly allocated to an experimental group AEDWR (aquatic exercises plus deep-water running group, N.=25) or to a control group AE (aquatic exercises only group, N.=23). The dependent variables included functional status (Repeated Sit-to-Stand test), lumbar (Sorensen test) and abdominal (One Minute Abdominal test) muscle endurance, and physical performance (Maximum Physical Fitness test), which were measured before and after the 9-week intervention and at 21 weeks of follow-up.

RESULTS

Lumbar endurance was higher in the AEDWR group at the end of the treatment, with a mean difference (MD) of 43.2 seconds, 95% confidence intervals (CI) (9.6; 76.7), P=0.01, d̅=0.74, and better in the follow-up with MD=40.2 seconds, 95% CI (7.1; 73.3), P=0.02, d̅=0.71, than in the AE group. Participant performance also improved on the 9^th week in the AEDWR group, with an MD=0.53 kgf, 95% CI (0.008; 0.98), P=0.02, d̅=0.60.

CONCLUSIONS

The addition of deep-water running exercise to aquatic exercises improved lumbar muscle endurance and performance when compared with aquatic exercises only, and this effect was maintained during the follow-up to lumbar muscle endurance.

Effectiveness of walking versus mind-body therapies in chronic low back pain: A systematic review and meta-analysis of recent randomized controlled trials

PURPOSE

Walking and mind-body therapies (MBTs) are commonly recommended to relieve pain and improve function in patients with chronic low back pain (CLBP). The purpose of this study was to compare the effectiveness of walking and MBTs in CLBP.

METHODS

We included randomized controlled trials (RCTs) comparing walking or MBTs to any other intervention or control in adults with CLBP. Studies were identified through PubMed, Cochrane Library, PsycINFO, Scopus, and ScienceDirect databases. The research was limited to studies published in English and French between January 2008 and December 2018. Two reviewers independently selected the studies, extracted data, and assessed studies quality using the Physiotherapy Evidence Database (PEDro) scale. Statistical analyses were performed under a random-effects model. We analyzed pain and activity limitation, with the calculation of standardized mean differences and 95% confidence intervals for the different treatment effects.

RESULTS

Thirty one randomized controlled trials involving 3193 participants were analyzed. Walking was as effective as control interventions in the short-term and slightly superior in the intermediate term with respect to pain (Standardized mean differences (SMD)  = -0.34; 95% CI, -0.65 to -0.03; P = .03) and activity limitation (SMD = -0.30; 95% CI, -0.50 to -0.10; P = .003). In contrast, yoga was more effective than control interventions in the short term in terms of pain (SMD = -1.47; 95% CI, -2.26 to -0.68; P = .0003) and activity limitation (SMD = -1.17; 95% CI, -1.80 to -0.55; P = .0002). Yoga was no longer superior to the control interventions for pain at the 6-month follow-up.

CONCLUSION

MBTs, especially yoga, seem to be more effective in the short term, and walking seems to be more effective in the intermediate term, for the relief of pain and activity limitation in patients with CLBP. A combination of walking and MBTs fits the biopsychosocial model and might be valuable therapy for CLBP throughout follow-up due to combined effects.

[Treatment of non-specific low back pain: Evidence map of systematic reviews from 2015 to 2019]

BACKGROUND

Low back pain represents a major healthcare challenge in Germany and worldwide. The research field is highly dynamic. The aim of this evidence map was to create a compact overview of current systematic reviews on interventions for non-specific low back pain.

METHODS

Medline (PubMed), the Cochrane Database of Systematic Reviews and Epistemonikos were systematically searched from March 2015 to March 2019 for systematic reviews addressing any interventions for acute, subacute or chronic non-specific low back pain and reporting at least one patient-relevant outcome. Key information on the characteristics and conclusions of the included reviews were extracted and aspects of the methodological quality of the included reviews were assessed independently by two reviewers. The data were tabulated.

RESULTS

The search identified 1,436 records. 53 systematic reviews were included in the evidence map. The quality of the reviews and of the studies included therein varied. The reviews addressed a variety of different interventions, with considerable heterogeneity of their characteristics and methodological aspects. Many reviews found evidence for positive effects of the studied interventions, some found evidence for no effect, but the quantity and quality of the evidence were often judged as insufficient for formulating robust conclusions. Relatively few data were available on adverse events.

CONCLUSION

This evidence map provides a compact resource for the use of current systematic reviews on interventions for non-specific low back pain. The methodological deficits of many reviews require a careful approach towards their findings and conclusions and suggest a need for methodologically rigorous reviews.

Back rehabilitation - The 3R's approach

Exercise is vital to the management of low back pain (LBP). However, research, social media, and fitness industry interests can leave therapists confused about best practice in exercise prescription for this clinical condition. The 3R's approach to back rehabilitation is introduced as an evidence-based framework for developing patient specific exercise throughout the back-pain journey. Clinical guidelines for the management of LBP are presented, and both exercise and psychological considerations are overviewed. The contrast between biomedical and biopsychosocial models of healthcare is introduced in relation to LBP and the requirements of a successful rehabilitation programme. Interacting factors in LBP, red flags, and motor skill classification are considered. The concept of tissue capacity is introduced, and the healing timescale addressed. Both are used as a foundation for exercise choice and progression. Simple methods of structuring an exercise programme are drawn from the fitness industry and adapted for use in rehabilitation. The 3R's approach consists of 3 interrelated and overlapping phases - reactive, recovery, and resilience. Treatment aims for each are introduced with guidance given to indicate appropriate patient progression between phases. Exercise examples of each stage are illustrated with consideration given to clinical reasoning, teaching method, safety and effectiveness.

Nonsurgical treatments for patients with radicular pain from lumbosacral disc herniation

BACKGROUND CONTEXT

Lumbosacral disc herniation (LDH) is one of the most frequent musculoskeletal diseases causative of sick leave in the workplace and morbidity in daily activities. Nonsurgical managements are considered as first line treatment before surgical treatment.

PURPOSE

This clinical practice guideline (CPG) is intended to provide physicians who treat patients diagnosed with LDH with a guideline supported by scientific evidence to assist in decision-making for appropriate and reasonable treatments.

STUDY DESIGN/SETTING

A systematic review.

PATIENT SAMPLE

Studies of human subjects written in Korean or English that met the following criteria were selected: patients aged ≥18 years, clinical presentation of low back and radicular leg pain, diagnosis of LDH on radiological evaluation including computed tomography or magnetic resonance imaging.

OUTCOMES MEASURES

Pain and functional evaluation scales such as visual analogue scale, numeric rating scale, and Oswestry disability index METHODS: The MEDLINE (PubMed), EMBASE, Cochrane Review, and KoreaMed databases were searched for articles regarding non-surgical treatments for LDH published up to July 2017. Of the studies fulfilling these criteria, those investigating clinical results after non-surgical treatment including physical and behavioral therapy, medication, and interventional treatment in terms of pain control and functional improvements were chosen for this study.

RESULTS

Nonsurgical treatments were determined to be clinically effective with regards to pain reduction and functional improvement in patients with LDH. Nevertheless, the evidence level was generally not evaluated as high degree, which might be attributed to the paucity of well-designed randomized controlled trials. Exercise and traction were strongly recommended despite moderate level of evidence. Epidural injection was strongly recommended with high degree of evidence and transforaminal approach was more strongly recommended than caudal approach.

CONCLUSIONS

This CPG provides new and updated evidence-based recommendations for treatment of the patients with LDH, which suggested that, despite an absence of high degrees of evidence level, non-surgical treatments were clinically effective.

Best Evidence Rehabilitation for Chronic Pain Part 3: Low Back Pain

Chronic Low Back Pain (CLBP) is a major and highly prevalent health problem. Given the high number of papers available, clinicians might be overwhelmed by the evidence on CLBP management. Taking into account the scale and costs of CLBP, it is imperative that healthcare professionals have access to up-to-date, evidence-based information to assist them in treatment decision-making. Therefore, this paper provides a state-of-the-art overview of the best evidence non-invasive rehabilitation for CLBP. Taking together up-to-date evidence from systematic reviews, meta-analysis and available treatment guidelines, most physically inactive therapies should not be considered for CLBP management, except for pain neuroscience education and spinal manipulative therapy if combined with exercise therapy, with or without psychological therapy. Regarding active therapy, back schools, sensory discrimination training, proprioceptive exercises, and sling exercises should not be considered due to low-quality and/or conflicting evidence. Exercise interventions on the other hand are recommended, but while all exercise modalities appear effective compared to minimal/passive/conservative/no intervention, there is no evidence that some specific types of exercises are superior to others. Therefore, we recommend choosing exercises in line with the patient's preferences and abilities. When exercise interventions are combined with a psychological component, effects are better and maintain longer over time.

Treatment of patients with acute and subacute dorsalgia

Objective: to investigate the efficiency of treatment for acute and subacute dorsalgia, by providing information to patients and by using nonsteroidal anti-inflammatory drugs (NSAIDs) without conducting physical therapy, reflexotherapy, and manual therapy. Patients and methods. A total of 140 patients (87 women and 53 men; mean age 50.7±17.6 years) with acute and subacute back pain were followed up. Out of them 127 (91%) patients were found to have nonspecific (musculoskeletal) pain; 13 (9%) had discogenic radiculopathy. All the patients were informed of the benign nature of the disease, the high probability of its rapid resolution, the feasibility of abandoning prolonged bedrest, and the lack of need for physical therapy, reflexotherapy, massage, and manual therapy. To reduce pain, the patients received meloxicam 15 mg/day orally or intramuscularly or first 15 mg/day intramuscularly and then orally. The investigators assessed pain intensity with the numerical rating scale and functional activity restrictions with the Roland-Morris disability (RMD) questionnaire. Results. After treatment, the visual analogue scale pain intensity scores decreased from an average of 6.4 to 1.0; the RMD scores dropped from 6.8 to 1.4 (p<0.001). The duration of treatment averaged 11.0±4.4 days. Comparison of different meloxicam dosage regimens showed no significant differences; a positive result was noted in all cases. No adverse events were observed during treatment. Conclusion. The investigation has shown the high efficiency of management in patients with acute and subacute dorsalgia, by providing information to patients (an education conversation), by using meloxicam, and by applying a personalized approach (treatment for concomitant diseases and conditions). Refusing physiotherapy, massage, acupuncture, and manual therapy substantially reduces the cost of treatment in patients with acute dorsalgia.