Increasing Recreational Physical Activity in Patients With Chronic Low Back Pain: A Pragmatic Controlled Clinical Trial

Abstract

Study Design Prospective, pragmatic, nonrandomized controlled clinical trial. Background Clinical guidelines recommend physical activity for the treatment of chronic low back pain. But engaging patients in physical activity has proven difficult. Known obstacles to physical activity include low self-efficacy and fear avoidance. Objectives This study tested the effectiveness of an enhanced transtheoretical model intervention (ETMI) aimed at increasing recreational physical activity in patients with chronic low back pain, in comparison to usual physical therapy. Methods Patients (n = 220) referred to physical therapy for chronic low back pain were allocated to ETMI or to a control group. The ETMI was delivered by physical therapists and based on behavior-change principles, combined with increased reassurance, therapeutic alliance, and exposure to reduce fear avoidance. The primary outcome was back pain-related disability (Roland-Morris Disability Questionnaire). Secondary outcomes included pain intensity, mental and physical health, and levels of physical activity. Results Intention-to-treat analysis in 189 patients at 12 months indicated that patients in the ETMI group had significantly lower disability compared to usual physical therapy. The difference in mean change from baseline between the interventions was 2.7 points (95% confidence interval: 0.9, 4.5) on the Roland-Morris Disability Questionnaire. At 12 months, worst pain, physical activity, and physical health were all significantly better in patients receiving ETMI. The average number of sessions was 3.5 for the ETMI group and 5.1 for controls. Conclusion Targeting obstacles to physical activity with an intervention that includes components to address self-efficacy and fear avoidance appears to be more effective than usual physical therapy care in reducing long-term disability. Further research is needed to explore the mechanisms that impact outcomes in this intervention package. Level of Evidence Therapy, level 2b. Registered June 7, 2012 at ClinicalTrials.gov (NCT01631344). J Orthop Sports Phys Ther 2017;47(2):57-66. doi:10.2519/jospt.2017.7057.

Behaviour change techniques associated with adherence to prescribed exercise in patients with persistent musculoskeletal pain: Systematic review

“…Additionally, this review only included interventions with an exercise prescription, and not general PA. PA, such as walking (O'Connor et al, 2015) and habitual PA (Ben-Ami et al, 2017), have been found to decrease pain in this population. Future reviews should further explore adherence to PA interventions in a population with PMSK.…”

The effects of behavioural counselling on the determinants of health behaviour change in adults with chronic musculoskeletal conditions making lifestyle changes: A systematic review and meta‐analysis

“…The format of delivery of the behavioural counselling interventions varied between trials (Table ). In four trials (Ben‐Ami et al, ; Friedrich et al, ; Lonsdale et al, ; Vong et al, ), behavioural counselling was delivered in conjunction with physiotherapy. Behavioural counselling was also delivered alongside a prescribed exercise routine including supervised exercise sessions (Ang et al, ), with occupational therapy (Niedermann et al, , ) and with cognitive behavioural therapy (Kerns et al, ).…”

“…PA and home exercise completion was measured in nine trials (Table ). PA was measured using only self‐reported questionnaires in seven trials (Allen et al, ; Ben‐Ami et al, ; Friedrich et al, ; Knittle et al, , ; Lonsdale et al, ; Vong et al, ; Williams et al, ), both a self‐reported questionnaire and accelerometry in one trial (Ang et al, ) and accelerometry only in one trial (Gilbert et al, ). Where multiple self‐reported measures were used, time duration was the most commonly used unit of measure.…”

Chronic Pain and Exercise: Studies on pain intensity, biochemistry, adherence and attitudes

“…In future studies and clinical application of PA&E as treatment, it is therefore interesting to further emphasize behavioural strategies for increased adherence to the prescribed PA&E, separate from and parallel to behavioural approaches focusing on the chronic pain. This speculation of the importance of behavioural strategies to enhance adherence to prescribed PA&E is in line with the conclusion in paper 4, and to the results of one recent study showing improved adherence to recreational PA&E as well as improved pain related outcomes when behaviour change strategies were included in the intervention design [245].…”

“…PA&E are health behaviours. However, health behaviour change theories are surprisingly rarely included in studies on PA&E as treatment for chronic pain, even though recently one study reports relations between core constructs within the SDT and the Theory of Planned Action applied on individuals with chronic pain [239], and one study showed that interventions based on the Transtheoretical Model [244] increased recreational PA&E in patients with chronic low back pain [245].…”