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QUESTION: In patients with subacute or chronic low back pain, does a community exercise programme help them return to normal activities?
General practices in the York region of England.
187 patients who were 18 to 60 years of age (mean age 42 y, 57% women), had mechanical low back pain for ≥4 weeks but <6 months, and were deemed medically fit for exercise by their general practitioners (GPs). Exclusion criteria included serious spinal pathological findings, concurrent use of physiotherapy, or inability to attend exercise classes. Follow up was 87% and 91% at 6 and 12 months, respectively.
Patients were allocated to an exercise program, 8 one hour sessions over 4 weeks (n=89) or to a control group (n=98). The exercise program consisted of stretching, low impact aerobic, and strengthening exercises aimed at all main muscle groups; cognitive behavioural principles were used in these sessions to promote self reliance. Patients in the control group received standard care from their GPs.
Main outcome measures
Functional limitation (24 point Roland back pain disability questionnaire), clinical status (Aberdeen back pain scale), quality of life (EuroQoL health index and the Fear-Avoidance Beliefs Questionnaire), use of health care services, and costs.
Patients in the exercise programme had greater improvement in function than did those in the control group at 6 months and 12 months (difference in mean change from baseline scores on Roland questionnaire 1.35, 95% CI 0.13 to 2.57 at 6 mo; 1.42, CI 0.29 to 2.56 at 1 y) (table). The exercise program also led to better clinical status at 12 months than did usual care (difference in mean change from baseline scores on Aberdeen questionnaire 4.44, CI 1.01 to 7.87). The EuroQoL health index did not differ between groups at 6 and 12 months.
The use of health care resources was greater in the control group than in the exercise group, but the difference in costs at 12 months was not statistically significant. Patients in the exercise group reported having a total of 378 days off work (4.2 d per patient), whereas those in the control group reported a total of 607 days off work (6.2 d per patient). Patient treatment preference did not influence the outcome.
In patients with subacute or chronic low back pain, a community exercise programme improved function and clinical status at 12 months.
Convincing evidence shows that exercise of any kind is not useful for acute low back pain. Instead, patients tend to do best when they continue their usual daily routines.1 Conversely, high quality studies show exercise to be effective in low back pain >6 months in duration.2, 3
The study by Moffett and colleagues evaluated the role of exercise in patients with subacute to chronic pain (lasting from 4 wk to 6 mo). This period was chosen because the rate of recovery tends to slow at 4 weeks. The exercises used by the authors are described in a previous article2 and can be easily replicated.
The authors suggest that patients with lowback pain are afraid to move, which delays recovery. The goal of the self reliance counselling included in their classes was to avoid the adoption of the “sick role” by patients. This approach makes sense in light of the link between low back pain, depression, and somatic illnesses. Using a cognitive behavioural model to promote early recovery (before the sick role is firmly entrenched) is a strategy that could help in this common cause of disability.
Sources of funding: Arthritis Research Campaign; Northern and Yorkshire Regional Health Authority; National Back Pain Association.
For correspondence: Dr JK Moffett, Institute of Rehabilitation, University of Hull, Hull HU3 2PG, UK. Fax +44 (0)1482 675636.
↵† Information supplied by author.