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  • Separate Studies Support Exercise to Treat, Prevent LBP

    Research continues to support the effectiveness of exercise when it comes to low back pain (LBP)—not only as a way to treat existing LBP, but as a way to prevent it.

    A new systematic review and meta-analysis in JAMA Internal Medicine (abstract only available for free) assessed research into the value of exercise as a way to prevent episodes of LBP. It found that exercise alone was linked to a 35% reduction in risk, while a combination of exercise and education was associated with a 45% risk reduction for up to 1 year. The use of exercise was also found to result in a 78% reduction in sick leave for LBP.

    The review was based on 23 published studies involving 30,850 participants, and looked at the preventive qualities not only of exercise and education (both combined and separately), but also of back belts and orthotic shoe insoles. In the end, only exercise was linked to a reduced risk of LBP: authors of the study found that while education helped to further reduce that risk when combined with exercise, education alone didn't seem to have much effect.

    The problem: the risk reduction benefits of exercise "disappeared" after 1 year. Authors attribute the dropoff to some individuals discontinuing the exercise program.

    "The finding raises the important issue that, for exercise to remain protective against future LBP, it is likely that ongoing exercise is required," authors write. "Prevention programs focusing on long-term behavior change in exercise habits seem to be important."

    Also Works for Treatment of Chronic LBP
    While the JAMA authors focused on prevention, researchers whose findings were included in a recently updated Cochrane review ( currently, abstract only available for free; complete article will be made available via APTA's ArticleSearch in the coming weeks) aimed at evaluating the evidence supporting exercise—specifically motor control exercise (MCE) to coordinate and stabilize deep trunk muscles—as a treatment for chronic LBP.

    Their conclusion was that MCE "probably provides better improvements in pain, function, and global impression of recovery" than minimal intervention at all follow-up periods (these varied by study), and that it "may" provide better improvements than exercise and electrophysical agents. Authors found results to be about the same when it came to MCE versus manual therapy, and MCE versus "other forms of exercise." The analysis was based on 29 trials involving 2,431 participants.

    "Given the minimal evidence that MCE is superior to other forms of exercise, the choice of exercise for chronic LBP would probably depend on patient or therapist preferences, therapist training, costs, and safety," authors write.

    'Uncommonly Prescribed'
    In an invited commentary on the JAMA article, authors Timothy Carey, MD, and Janet Freburger, PT, PhD, focus on the LBP prevention study, but the main point they raise—the need for more widespread use of exercise prescriptions—could apply to the MCE study as well.

    "If a medication or injection were available that reduced LBP recurrence by [the amounts cited in the JAMA article], we would be reading the marketing materials in our journals and viewing them on television," commentary authors write. "However, formal exercise instruction after an episode of LBP is uncommonly prescribed by physicians." They describe the gap as part of a pattern in the treatment of musculoskeletal problems "in which effective but lower-technology and often lower-reimbursed activities are underused."

    Carey and Freburger describe several barriers to more common use of exercise instruction that include a lack of consensus around "standard, efficient, and acceptable bundled intervention" for LBP, unclear understandings of the role of patient education, questions about how best to motivate patients, a paucity of cost-effectiveness studies, hesitancy among payers to support exercise programs, and a shortage of clinicians "able to describe, with confidence, the benefits of easily accessible exercise programs to diverse patient populations."

    "To address these barriers, payers, professional societies, consumers, and members of health care delivery systems will need to work together," write Carey and Freburger, adding that if they do, "the potential benefits to the health system, patients, and employers are substantial."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Comments

    • Very gratifying to confirm what I have found in practice with treating LBP. The majority of my LBP patients do extremely well with a treatment program that always includes education on ergonomics and a good basic strengthening program as well as manual therapy where indicated.

      Posted by Nadine De Freitas, DPT, PT, ATC on 1/13/2016 6:21 PM

    • What research has been done on what percentage of patients are going to follow up on home ex. programs. My 45 years of practice states that only about 20-25% will follow up and therefore in Clinic exercising becomes extremely important to help cut overall medical costs.

      Posted by Reid Molen on 1/13/2016 6:28 PM

    • Interesting. Using non-specific exercise for a non-specific symptom. PTJ has really succeeded in nearly wiping out all reference to the sacroiliac joint although this might not be a good thing. It's still there... and responsive to specific exercise. 14. DonTigny R L. Measuring PSIS movement. Clinical Management. 1990. 10:43-44. 15. Yeoman W. The relation of arthritis of the sacroiliac joint to sciatica. Lancet. 1928. 2:1119-1122. 16. Frieberg A H, Vinke TH. Sciatica and the sacroiliac joint. J Bone & Joint Surg. 1934.16:126. 17. McConnell CP, Teall CC. The Practice of Osteopathy. Third Edition. Kirksvillle, Mo., The Journal Printing Co. 1906. 18. Baer WS. Sacro-iliac strain. Bull. Johns Hopkins Hosp. 1917. 28: 159. 19. Norman GF. Sacroiliac disease and its relationship to lower abdominal pain. Am J Surg. 1968.116:54-56. 20. Norman G F, May A. Sacroiliac conditions simulating intervertebral disc syndrome. West J Surg Obstet Gynecol. 1956.461-462. 21. Chamberlain WE. The symphysis pubis in the roentgen examination of the sacroiliac joint. Am J Roentgenol Radium Ther Nucl Med. 1930.24:621-625.

      Posted by Richard DonTigny, PT on 1/13/2016 6:56 PM

    • Great article. I would like to connect with other PT's who are offering onsite fitness classes for health and wellness at their local town businesses for those industry employees. I am planning to offer such services in my area outside of Dallas, TX, and would like some advise (contracts used, liability waivers, exercise programs used, etc.).

      Posted by Wendy McLean on 1/13/2016 11:56 PM

    • Tragically, the evidence is trumped by $$$. We need to have better public relations AND political action to get the 'healthcare system' (still an oxymoron) to recognize and engage our services in an optimal way. Thank you for getting the work and words out to our own profession. Britt Smith PT, DPT, OCS, FAAOMPT.

      Posted by Britt Smith -> AFV]A on 1/15/2016 7:37 AM

    • manual therapy, simple exercise prescription and motivational interviewing could become a triad

      Posted by Michele Wirth on 1/22/2016 11:18 AM

    • Wendy McLean- we offer onsite fitness classes here in Rochester. I've been teaching for over 5 years. elizabeth_wetmore@urmc.rochester.edu UR Medicine: University Sport & Spine Rehab.

      Posted by Elizabeth Wetmore on 2/3/2016 12:23 PM

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