Journal of Yoga & Physical Therapy
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The Effects of a Daily Short Duration Mobility and Exercise Program on Individuals with Chronic Low Back Pain: A Pilot Study

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Introduction

Chronic pain is a debilitating healthcare issue affecting many individuals throughout the world with the most common condition being chronic low back pain (cLBP) [1]. For low back pain to be considered a chronic condition, it must be present for >3 months. In the United States cLBP currently holds a one-year mean prevalence rate of 38.1% conducted a systematic review in 2015 which found the prevalence of back pain to be 19.6% in individuals between the ages of 20 and 59 and this study helped demonstrate cLBP increases linearly from the third to sixth decade of life [1,2]. In addition to the detriment of living life in pain, the population suffering spinal issues also faces a financial burden, paying an average of $4,695 in medical fees per year compared to their pain-free counter parts average of $2,731 [3].

CDC national trends illustrate many Americans currently do not meet the ACSM minimum exercise recommendations of 150 minutes per week with bouts of exercise lasting at least 10 minutes. Sedentary lifestyle factors are likely contributing to common impairments associated with LBP including poor core or glute strength [4,5] poor hip and spinal mobility [5-8] or postural dysfunction. Although it is well known a sedentary lifestyle correlates with a variety of issues including cLBP [9,10]. The NIH states many factors deterring Americans from exercising daily include poor adherence, and a lack of time, motivation and access to resources.

Although a large variety of treatment options exist for individuals with cLBP, opioids are often the first line of treatment and are prescribed in over 70% of LBP cases because they provide an acute analgesic effect [11]. While the analgesic effect can be beneficial for short-term pain, opioids may not provide long-term relief as past research shows opioids do not improve the daily functioning in someone with LBP [12]. Based on current Centers for Disease Control and Prevention (CDC) data opioids are displaying a rapid increase in deaths and abuse. The National Institute of Health (NIH) states that nearly 130 people die each year from the abuse of opioids with an estimated financial burden of $78.5 billion per year. While opioids provide pain relief, it may prove to be beneficial to develop more alternative modes of conservative treatment for chronic LBP.

A current alternative method for treating cLBP is implementing mobility programs such as yoga. Yoga has demonstrated to be beneficial on individuals with mild to moderate cLBP [13]. Yoga has been proven to have both short and long-term relief of cLBP and research supports its use in managing pain and dysfunction associated with LBP [13,14]. However, explains yoga required a time commitment which ranged from 30 to 90 minutes, ranging from weekly to twice-weekly sessions [15]. The time commitment and relatively high cost of yoga classes increase the likeliness for poor adherence and often individuals of higher socioeconomic status are capable of participating [16]. An area of research lacking evidence for the treatment and prevention of cLBP is the use of a daily full-body mobility program as a way to save time and money while decreasing pain and increasing function. Found a progressive walking program to be an effective treatment option for the management of LBP [17]. Walking proved to be a comparable and effective option to manage chronic LBP due to the low cost and increased level of adherence.

The etiology of LBP is complex and multifactorial in nature, making it difficult to determine the most effective and efficacious plan of care for each patient [18,19]. Therefore, the aim of this study is to find an effective method that a variety of people can integrate into their daily life and reduce the barriers to exercise.

Methods

Recruitment

Potential participants were contacted via email through franklin Pierce University Goodyear, Arizona DPT program and a local physical therapy clinic contact database (Impact Physical Therapy). Those who responded as interested were then added to our contact list. Screening then took place via phone by four DPT student researchers.

Participants

Seventy four adults with chronic low back pain were contacted via phone and those that met the inclusion criteria were invited to participate in the study. Our study then consisted of a sample size of 15 adults (8 males, 7 females) with a mean age of 34 years of age (mean=34.77). This study was approved by the Institutional Review Board (IRB) under the protection of human subjects by the Declaration of Helsinki.

Inclusion Criteria

This study included adult participants aged 18-65 with selfreported LBP for a minimum of three months. Participants were excluded if they were currently participating in physical therapy or any form of mobility program. Participants were excluded if they had complaints of any radiating pain or numbness, tingling or burning past the knee that was greater than a 5/10 conducted via visual analog scale (VAS), had complaints of severe hip pain or any recent shoulder, elbow or hand pain as this could be exacerbated by positions in our stretching routine. Additionally, subjects must have denied any uncontrolled cardiac pathologies, recent changes in bowel and bladder function, orthostatic hypotension with exercise or changes in position and dizziness or vertigo. Eligible participants did not have any systemic diseases or disorders, did not demonstrate or report any cognitive deficits or mental health illness and were not pregnant. Finally, our participants were not to have had any surgeries in the past six months, falls within the past one year or previous history of a spinal fusion.

Initial Assessment

Participants were initially assessed by a licensed Doctor of Physical Therapy (DPT). Upon arriving to the appointment, each participant signed a written informed consent, filled out an intake form (including a brief medical history, a body chart and a visual analog scale for pain ranging from 0-10) and completed four outcome measures (Fear Avoidance Belief Questionnaire, Oswestry Low Back Pain Disability Questionnaire, Pain Catastrophizing Scale and SF-36).

The outcome measures used included the Fear Avoidance Belief Questionnaire (FABQ), Oswestry Low Back Pain Disability Questionnaire, Pain Catastrophizing Scale and SF-36.

Fear-avoidance belief questionnaire: The FABQ is a valid and reliable outcome measure that was chosen to examine how fearavoidance beliefs may affect a person’s pain [20-23].

Oswestry low back pain disability questionnaire: The oswestry Low Back Pain Disability Questionnaire is a valid and reliable outcome measure was used to examine severity of symptoms of LBP with activities of daily living (ADLs) [24-26].

Pain catastrophizing scale: The Pain Catastrophizing Scale is a valid and reliable outcome measure used to assess patients to indicate subjective thoughts or feelings they have about their pain [27,28].

SF-36: The SF-36 is a valid and reliable outcome measure that includes 36 items encompassing eight categories including physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy/fatigue, emotional well-being, social functioning, pain and general health [29].

Randomization and Procedure

The study design was conducted as a randomized control trial with a convenience sample. Participants were randomly assigned to either a dynamic stretching group (DSG) or a walking group (WG) via a random number generator prior to their initial assessment.

Vital signs including pulse rate, SPO₂ and blood pressure, were taken on each participant in compliance with ACSM guidelines to safely engage in exercise. Blinded to the group selection for each individual, two doctors of physical therapy (DPT) performed preliminary mobility and pain provocation screens of each participant. Active range of motion (AROM) of thoracolumbar and hips were obtained and any pain by the participant was noted.

Following randomization and initial assessment, participants in each group met with a physical therapy student who provided standardized verbal and visual instruction in the respective group protocol. Both groups were instructed to perform their respective routine at least five days a week for three weeks Subjects were given a log to keep track of their activity [30]. Subjects were instructed to stop activity and notify their student contact if their pain increased from baseline. Student researchers followed up with each subject at least once per week via the participant’s preference of email, test or phone call to ensure exercise adherence.

Walking Group Protocol

Participants in the WG were given an RPE scale and instructed to walk 12 minutes at a self-selected moderate intensity, correlating with a 4-6/10 on the RPE scale (ACSM) [31,32]. Individuals were given the option to walk on a treadmill or outdoors.

Dynamic Stretching Group Protocol

DSG participants were provided access to a private you tube link containing the short duration dynamic stretching routine. Each subject performed the routine in full at the end of their assessment appointment while being supervised by a student physical therapist to ensure proper form. The dynamic stretching exercises used in the patient video are listed in Table 1 titled Dynamic Stretching Exercises.

Table 1: Dynamic Stretching Exercises

Final Evaluations

At the conclusion of the three-week intervention, subjects were provided the same outcome measures as the initial assessment via email to complete on the last day of their routine. Participants were then scheduled at their convenience to return to the testing facility for re-assessment. During this re-assessment, the physical therapists repeated initial mobility and pain provocation tests, and the subjects were able to submit the completed outcome measures. Participants were evaluated by the same DPT as the preliminary assessment to ensure consistency across the participant experience.

Statistical Analysis

Statistical tests were performed via SPSS. Wilcoxon Signed-Ranks tests were performed to compare pre- and post-scores for each outcome measure for all participants. Kruskal Wallis test was performed to compare overall changes from the DSG to the WG. The level of statistical significance was set at (P < 0.05). An analysis of power was not performed due to our study design being a pilot study to show feasibility in preparation to plan a larger study in the future.

Results

A total of 18 subjects were chosen to participate in the study after completing the phone screening. Mean age of participants (N=15) was 34.77 outcome measure responses before and 3 weeks after for both the SG and WG are displayed in Table 2. There was no statistically significant improvement in the WG. However, the DSG experienced significant differences in VAS (p = 0.011), Oswestry (p = 0.047), SF-36 energy/fatigue item (p = 0.047), SF-36 pain item (p = 0.027) and SF-36 general health item (p=0.041). When comparing the change in outcome measures between the WG and DSG, a Kruskal- Wallis analysis found two outcome measures that were significantly different (p-value < 0.05). The DSG showed significantly improved scores related to Fear Avoidance Behavior Questionnaire (p=0.019) and the Pain Catastrophizing scale (p=0.026). Table 2 quality of life outcome tool results lists the statistical data collected for each of the quality of life tools assessed pre and post.

Table 2: Quality of Life Outcome Tool Results.

Withdrawals

Three subjects did not complete the duration of the study. Two participants were dismissed due to not meeting the adherence requirement of performing their activity five times per week. One participant was deemed inappropriate at the initial evaluation secondary to concurrent physical therapy for hip pain.

Discussion

Roughly one quarter of the American population suffer from back pain [1,2]. In addition, CDC data indicates activity levels are currently at an all time low in the United States and are trending downward. Extensive research has shown the benefits of physical activity on back pain and general health. However, minimal research has proven the benefits of a short duration daily mobility program.

Although general exercise, such as walking, is beneficial for a variety of conditions, this study revealed short bouts of walking may not be the most effective primary intervention for individuals with CLBP. The results indicate a mobility routine can be beneficial for adults with LBP when compared with individuals performing the same duration of walking. Demonstrated daily walking was effective in reducing pain and functional disability associated with LBP [33]. This study differed in that subjects were not progressed per the ACSM guidelines for daily exercise. Found isometric stretching to be beneficial for improving quality of life in patients with chronic LBP, a SF-36 outcome measure was utilized for quantifying the subject’s perceived improvement in quality of life [34]. The present study showed statistically significant improvements in the DSG using the SF-36 items of energy/fatigue, pain and general health.

In both study groups, statistically significant differences were seen in both the FABQ and Pain Catastrophizing Scale scores at follow-up. When compared with the WG, the DSG demonstrated greater significance in both the FABQ and Pain Catastrophizing Scale scores, suggesting dynamic stretching may be more beneficial for reduction in fear avoidance behaviors than walking alone. The greater benefits seen in the DSG may stem from tri-planar motion occurring when performing the specified movements. As highlights, CLBP often leads to altered movement and/or control patterns, which in turn results in abnormal spinal loading and often increased pain (2000) [35]. The mobility program utilized in this study encourages movement into all planes rather than moving primarily in the sagittal plane, which is typical during walking. Encouraging participants to move in a tri-planar, dynamic nature may contribute to decreased feelings of fear avoidance.

Conclusion

Pain and fear avoidance behaviors are two of the most common impairments associated with cLBP in addition to decreased quality of life. The results of this study suggest a short mobility routine is superior to the same duration of walking for improving participants’ perceptions of energy level, pain and general health. These results may be applied when determining appropriate home exercise prescription and dosing for patients with LBP. This may aid in maximizing compliance and improving patient satisfaction.

Limitations

This study used a convenience sample with participants from franklin pierce University and former patients of a local physical therapy clinic. Although subjects filled out accountability logs demonstrating adherence to their assigned protocol, the researchers are unable to further verify subjects were fully adherent as they were not directly supervised by the research team. Although there were statistically significant changes in scores for some of the outcome measures, the sample size was a small convenience sample and thus cannot be generalized to the population.

Future Research

Future research is needed to duplicate these results with a larger sample size. Additionally, more research is necessary to determine the minimal time frame of a mobility program necessary to produce favorable outcomes for patients with CLBP.

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