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Exercise and the Prevention of Low Back Pain



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May 13, 2010

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Low Back PainMany occupations in modern society require prolonged sitting which has been shown to be a risk factor for low back pain.  There are numerous studies that suggest that exercise can play an important role in preventing occupational and non-occupational low back pain.  An innovative approach was published this month (April 2010) in The Spine Journal that used an office chair exercise that is performed while seated.  The exercise, described in the article by Jerome Fryer, D.C., provides a brief decompression of the lumbar spine by moving forward on the chair seat, placing the hands on the seat of the chair, pressing downward with the arms to take pressure off the lumbar spine, and arching the back and shoulders backward at the same time.  This decompression maneuver held for 5 seconds followed by 3 seconds of reloading (sitting normally) and was repeated 4 times.  Sequential MRI demonstrated a marked increase in vertical height of the lumbar spine using this decompression strategy.  The authors concluded that “Seated upright MRI and stadiometry, as performed in this study, appear to be feasible methods for detecting compressive and decompressive spinal changes associated with normal sitting and, alternately, seated unloading exercises. Larger studies are encouraged to determine normative values of our study measurements and to determine if morphological changes induced by seated unloading predict treatment response and/or reductions in the incidence of sitting-related LBP.”

A January 2010 Cochrane review concluded that “There is moderate quality evidence that post-treatment exercise programs can prevent recurrences of back pain but conflicting evidence was found for treatment exercise”.  There have been many studies published this past decade that support the value of exercise in primary, secondary as well as tertiary prevention of low back pain.  These studies have been conducted with multiple age groups and multiple settings including sports venues and the workplace.

Magnetic resonance imaging and stadiometric assessment of the lumbar discs after sitting and chair-care decompression exercise: a pilot study.

Spine J. 2010 Apr;10(4):297-305. Epub 2010 Feb 26.

Fryer JC, Quon JA, Smith FW.
Nanaimo, British Columbia, Canada. drfryer@shaw.ca

BACKGROUND: Sitting is associated with loss of the lumbar lordosis, intervertebral disc (IVD) compression, and height loss, possibly increasing the risk of lower back pain. With a trend toward more sitting jobs worldwide, practical strategies for preventing lumbar flattening and potentially associated low back pain (LBP) are important.

PURPOSE: The purpose of this study was to determine the feasibility of using upright magnetic resonance imaging (MRI) and stadiometry to measure changes in height and configuration of the lumbar spine before and after normal sitting and a seated unloading exercise intervention.

STUDY DESIGN/SETTING: This is a hospital-based pilot study involving pre-post assessments in a single group. PATIENT SAMPLE: The sample comprises six asymptomatic hospital employees involved in either general patient care or research writing/data collection.

OUTCOME MEASURES: The outcome measures were lumbar total midsagittal cross-sectional IVD area, vertical height, lordotic angle derived from digitized MRI examinations, and seated body height measured directly with a stadiometer.

METHODS: Midsagittal MRI scans were performed before sitting, after 15 minutes of relaxed sitting ("postsitting"), immediately after seated unloading exercises, and approximately 7 minutes after exercise. Subsequently, seated stadiometry assessments were performed after 10 minutes of supine recumbency, 15 minutes of relaxed sitting, and every 10 seconds after seated unloading exercises until three consecutive height measurements were identical. Digitized midsagittal images were used to derive MRI-based outcome measures. Measurements at postsitting were compared with the corresponding ones at other time points using multiple paired t-tests. The Bonferroni method was used to adjust for multiple pairwise comparisons.

MAIN RESULTS: After 15 minutes of sitting, mean total IVD area, lordotic angle, and vertical height of the lumbar spine decreased 18.6 mm(2), 6.2 degrees , and 12.5 mm, respectively, whereas after seated unloading exercises, these parameters increased by 87.9 mm(2), 5.0 degrees , and 21.9 mm, respectively. Similarly, mean seated height on stadiometry decreased by 6.9 mm after 15 minutes of sitting and subsequently increased by 5.7 mm after unloading exercises.

CONCLUSIONS: Seated upright MRI and stadiometry, as performed in this study, appear to be feasible methods for detecting compressive and decompressive spinal changes associated with normal sitting and, alternately, seated unloading exercises. Larger studies are encouraged to determine normative values of our study measurements and to determine if morphological changes induced by seated unloading predict treatment response and/or reductions in the incidence of sitting-related LBP.

Exercises for prevention of recurrences of low-back pain.

Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006555.

Choi BK, Verbeek JH, Tam WW, Jiang JY.
Health Services Research and Evaluation Division, Ministry of Health, College of Medicine Building, 16 College Road, Singapore, Singapore, 169854.

BACKGROUND: Back pain is a common disorder that has a tendency to recur. It is unclear if exercises, either as part of treatment or as a post-treatment programme, can reduce back pain recurrences.

OBJECTIVES: To investigate the effectiveness of exercises for preventing new episodes of low-back pain or low-back pain-associated disability.

SEARCH STRATEGY: We searched CENTRAL (The Cochrane Library 2009, issue 3), MEDLINE, EMBASE and CINAHL up to July 2009. SELECTION CRITERIA: Inclusion criteria were: participants who had experienced back pain before, an intervention that consisted of exercises without additional specific treatment and outcomes that measured recurrence of back pain or time to recurrence.

DATA COLLECTION AND ANALYSIS: Two review authors independently judged if references met the inclusion criteria. The same review authors independently extracted data and judged the risk of bias of the studies. Studies were divided into post-treatment intervention programmes and treatment studies. Study results were pooled with meta-analyses if participants, interventions, controls and outcomes were judged to be sufficiently homogenous.

MAIN RESULTS: We included 13 articles reporting on nine studies with nine interventions. Four studies with 407 participants evaluated post-treatment programmes and five studies with 1113 participants evaluated exercise as a treatment modality. Four studies had a low risk of bias, one study a high risk and the remainder an unclear risk of bias.We found moderate quality evidence that post-treatment exercises were more effective than no intervention for reducing the rate of recurrences at one year (Rate Ratio 0.50; 95% Confidence Interval 0.34 to 0.73). There was moderate quality evidence that the number of recurrences was significantly reduced in two studies (Mean Difference -0.35; 95% CI -0.60 to -0.10) at one-half to two years follow-up. There was very low quality evidence that the days on sick leave were reduced by post-treatment exercises (Mean Difference -4.37; 95% CI -7.74 to -0.99) at one-half to two years follow-up.We found conflicting evidence for the effectiveness of exercise treatment in reducing the number of recurrences or the recurrence rate.

AUTHORS' CONCLUSIONS: There is moderate quality evidence that post-treatment exercise programmes can prevent recurrences of back pain but conflicting evidence was found for treatment exercise. Studies into the validity of measurement of recurrences and the effectiveness of post-treatment exercise are needed.

The comparative effectiveness of a multimodal program versus exercise alone for the secondary prevention of chronic low back pain and disability.

PM R. 2009 Sep;1(9):798-808.

Ewert T, Limm H, Wessels T, Rackwitz B, von Garnier K, Freumuth R, Stucki G.
Department of Physical Medicine and Rehabilitation, Ludwig-Maximilian University, Munich, Germany.

OBJECTIVE: The objective of this study was to examine whether a multimodal, secondary prevention program (MP) is superior to a general physical exercise program (EP) in influencing the process leading to chronic low back pain (LBP) in nurses with a history of back pain.

DESIGN: The study was conducted as a randomized controlled parallel-group trial.

SETTING: The interventions were performed in a single center at the Department of Physical and Rehabilitation Medicine at the University of Munich in Germany.

PARTICIPANTS: A total of 235 nurses from 14 nearby hospitals and nursing homes who experienced at least one episode of back pain during the previous 2 years were invited into the study. Of these, 183 nurses were enrolled and 169 (83 in the MP and 86 in the EP) qualified for the intent-to-treat analysis.

INTERVENTIONS: The EP consisted of 11 group sessions, each lasting 1 hour. After introductory sessions, subsequent sessions included general physical strengthening and stretching exercises as well as instructions for a home-training program. The MP consisted of 17 group sessions of 1.75 hours and one individual session of 45 minutes. In addition to the full EP, the MP included 5 psychological units, 7 segmental stabilization exercises units, and 8 ergonomic and workplace-specific units.

MAIN OUTCOME MEASUREMENTS: The primary study end-point variable was pain interference, and the secondary study end-point variables were pain intensity and functioning as measured with the West Haven-Yale Multidimensional Pain Inventory and the Short Form-36, respectively. These study end-point variables were defined a priori.

RESULTS: There was no statistically significant difference between the 2 groups. Small-to-moderate effects were observed in both intervention programs across all study end-point variables. For pain interference, the effect size at 12 months after intervention was 0.58 in the MP and 0.47 in the EP.

CONCLUSIONS: A multimodal program is not superior to a general exercise program in influencing the process leading to chronic LBP in a population of nurses with a history of pain. The most likely explanation is a common psychological mechanism leading to improved pain interference that is irrespective of the program used. Considering the lower resources of the general exercise program, the expense for a multimodal program is not justified for the secondary prevention of LBP and disability.

Exercise reduces the intensity and prevalence of low back pain in 12-13 year old children: a randomised trial.

Aust J Physiother. 2009;55(2):97-104.

Fanucchi GL, Stewart A, Jordaan R, Becker P.
Physiotherapy Department, University of Witwatersrand, South Africa. gfanucs@mweb.co.za

QUESTION: Does an eight-week exercise program reduce the intensity and prevalence of low back pain in 12-13 year old children? Does it decrease the childhood physical risk factors for low back pain and promote a sense of well-being?

DESIGN: Randomised trial with concealed allocation and assessor blinding.

PARTICIPANTS: Seventy-two 12-13 year old children, who had complained of low back pain in the past three months.

INTERVENTION: The experimental group completed eight exercise classes of 40-45 minutes duration over eight weeks conducted by a physiotherapist, whilst the control group received no intervention.

OUTCOME MEASURES: The primary outcome was pain intensity measured on a 10-cm visual analogue scale. Secondary outcomes included 3-month prevalence of pain, childhood physical risk factors for low back pain, and sense of well-being. Measures were taken at baseline (Month 0), post-intervention (Month 3), and three months later (Month 6).

RESULTS: Pain intensity over the past month had decreased by 2.2 cm (95% CI 1.0 to 3.5) more for the experimental group than the control group at Month 3 and was still 2.0 cm (95% CI 0.5 to 3.5) less than the control group at Month 6. The absolute risk reduction for 3-month prevalence in low back pain in the experimental group was 24% (95% CI 4 to 41) compared with the control group at Month 3, and 40% (95% CI 18 to 57) at Month 6. There were also statistically-significant between-group differences in neural mobility.

CONCLUSION: Exercise is effective in reducing the intensity and prevalence of low back pain in children.

TRIAL REGISTRATION: Clinical trials NCT00786864.

Exercise for the primary, secondary and tertiary prevention of low back pain in the workplace: a systematic review.

J Occup Rehabil. 2009 Mar;19(1):8-24. Epub 2009 Feb 14.

Bell JA, Burnett A.
Centre for Research into Disability and Society, School of Occupational Therapy and Social Work, Curtin University of Technology, GPO Box U1987, Perth, WA, 6845, Australia. j.netto@curtin.edu.au

INTRODUCTION: Low back pain (LBP) is one of the most costly conditions to manage in occupational health. Individuals with chronic or recurring LBP experience difficulties returning to work due to disability. Given the personal and financial cost of LBP, there is a need for effective interventions aimed at preventing LBP in the workplace. The aim of this systematic review was to examine the effectiveness of exercises in decreasing LBP incidence, LBP intensity and the impact of LBP and disability.

METHODS: A comprehensive literature search of controlled trials published between 1978 and 2007 was conducted and a total of 15 studies were subsequently reviewed and analyzed.

RESULTS: There was strong evidence that exercise was effective in reducing the severity and activity interference from LBP. However, due to the poor methodological quality of studies and conflicting results, there was only limited evidence supporting the use of exercise to prevent LBP episodes in the workplace. Other methodological limitations such as differing combinations of exercise, study populations, participant presentation, workloads and outcome measures; levels of exercise adherence and a lack of reporting on effect sizes, adverse effects, and types of sub-groups, make it difficult to draw definitive conclusions on the efficacy of workplace exercise in preventing LBP.

CONCLUSIONS: Only two out of the 15 studies reviewed were high in methodological quality and showed significant reductions in LBP intensity with exercise. Future research is needed to clarify which exercises are effective and the dose-response relationships regarding exercise and outcomes.

[Back school for patients with non-specific chronic low-back pain: benefits from the association of an exercise program with patient's education]

[Article in Portuguese]

Acta Reumatol Port. 2008 Oct-Dec;33(4):443-50.

Andrade SC, Araújo AG, Vilar MJ.
Programa de Pós-Graduação em Ciências da Saúde da Universidade Federal do Rio Grande do Norte (UFRN), Natal, Brazil. sandra.andrade.fisio@gmail.com

OBJECTIVE: <<Back School>> has been used as a way of preventing and treating back pain since 1969, but reports in the literature on its effectiveness remain controversial. The purpose of this trial was to evaluate efficacy of a back school program for non- -specific chronic low-back pain.

PATIENTS AND METHODS: Seventy patients were randomized into two groups: experimental group (34 patients) and control group (36 patients). Experimental group patients participated in a theoretical and practical back school program, which was composed of 4 weekly classes of 60 minutes. Control group patients were allocated at a waiting list. Three evaluations took place (baseline, after 4 and 16 weeks). The following variables were analyzed: pain intensity (visual numeric analogue scale), functional disability (Roland-Morris Disability Questionnaire) and spinal mobility (Schöber index). Statistical analysis for intra-group and inter-group used significance level of p < 0.05.

RESULTS: 57 patients were analyzed (29 in experimental group and 28 in control group). A statistically significant improvement was observed only in the experimental group, regarding pain intensity, functional disability and spine mobility. Such improvements have persisted after 16 weeks in pain intensity and functional disability variables. In the inter-group analysis we observed a statistically significant difference in the second and third evaluations concerning the functional disability variables and spinal mobility.

CONCLUSION: The Back School program proposed in this study seems to be effective for non-specific chronic low back pain.

Low back pain interventions at the workplace: a systematic literature review.

Occup Med (Lond). 2004 Jan;54(1):3-13.

Tveito TH, Hysing M, Eriksen HR.
Department of Biological and Medical Psychology, University of Bergen, Norway. Torill.Tveito@psych.uib.no

OBJECTIVE: To assess the effect of controlled workplace interventions on low back pain (LBP) through a review of controlled studies. The rising costs of employees with LBP have resulted in an abundance of offers to society and organizations of interventions to prevent and/or treat the problem. Little is known of the effect of the different interventions.

METHODS: A systematic literature search based on the inclusion criteria: controlled trial, work setting and assessment of at least one of the four main outcome measures: sick leave; costs; new episodes of LBP; and pain. Effect of the interventions was reported for the four main outcome measures.

RESULTS: Thirty-one publications from 28 interventions were found to comply with the inclusion criteria. Exercise interventions to prevent LBP among employees and interventions to treat employees with LBP have documented an effect on sick leave, costs and new episodes of LBP. Multidisciplinary interventions have documented an effect on the level of pain.

CONCLUSIONS: The results show that there is good reason to be careful when considering interventions aiming to prevent LBP among employees. Of all the workplace interventions only exercise and the comprehensive multidisciplinary and treatment interventions have a documented effect on LBP. There is a need for studies employing good methodology.
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