Exercise as it relates to Disease/Transtheoretical model intervention vs standard therapy in increasing physical activity in sufferers of chronic low back pain

This is a critique of the following article: Increasing Recreational Physical Activity in Patients With Chronic Low Back Pain: A Pragmatic Controlled Clinical Trial (2017)

What is the background to this research?
Low back pain is considered to be an extremely common issue globally, is at the forefront of causes for work absence and inhibiting general well-being and physical activity, and was found to be the most common cause of disability in young adults. Clinical recommendations, and guidelines from the World Health Organisation on treating chronic low back pain encourage increasing patients physical activity levels, however as this paper discusses, common barriers to this include low self-efficacy and fear avoidance, as well as other physical, psychological and socio-environmental factors. The research conducted for this study aims to assess the effectiveness of utilising an enhanced transtheoretical model intervention (ETMI) to address these barriers and increase patients physical activity levels vs standard physical therapy.

Where is the research from?
The study was conducted in Israel within the Maccabi Healthcare Services physical therapy clinics with the approval of the Tel Aviv University. The research was published in the Journal of Orthopaedic & Sports Physical Therapy (2017). The authors of this study received an award for Excellence in clinical Inquiry for their work, supporting the quality of the research when it comes to assessing the treatment of chronic low back pain. Multiple authors have also conducted numerous other studies relating to physical health and chronic low back pain, supporting their experience on the topic.

What kind of research was this?
The completed study was a pragmatic clinical trial, focusing on the correlation between different treatment methods and their outcomes within the actual health practice rather than attempting to explain the reasons behind potential differences. Patients were non-randomly allocated upon arrival into either the intervention or the control group for treatment, meaning the study was performed as a non-randomised control trial. The pragmatic style of this study allows for the broader results of implementing the tested strategy in the wider community in an every day basis to be better assessed, rather than an explanatory style which would only provide results on whether a treatment could work in ideal, specific circumstances. This is one extreme of the two methods however, and a more explanatory method should also be implemented in a correlating study as well in order to develop the best possible understanding.

What did the research involve?
A total of 220 participants of both men and women between the ages of 25-55 were separated into the intervention and control groups with 109 going into intervention and 111 into control. All of these patients suffered from chronic low back pain of at least 3 months. Patients with certain conditions were excluded such as pregnancy, tumours, or fractures. Therapists were assigned to administer either standard therapy or the ETMI method. All patients received an initial 40 minute consult with follow ups limited to 20 or 30 minutes. Baseline measures were taken which included: Patients then received the therapy method in accordance with the group they were placed in, with a researcher following up at 3 months and then again at the conclusion of the study at 12 months. Those receiving the intervention treatment utilised the ETMI focusing on the following barriers to physical activity: Those in the control group received standard therapy including mobilisation, manipulation, postural training etc.
 * Body Mass Index (BMI)
 * Roland-Morris Disability Questionnaire (RMDQ)
 * Pain Intensity
 * Duration of pain
 * Health related quality of life
 * Low motivation
 * Low self-efficacy
 * Fear of movement

As the primary outcome variable (the RMDQ) was a self-reported questionnaire, this can lead to personal bias as the patients can often intentionally or sub-consciously attempt to paint a better image of themselves, which can undermine the conclusions of the research. The method also does not record or assess how much physical activity is being completed by participants from either group at any stage, which could have boosted the possibilities for analysis.

What were the basic results?
Results showed that in the ETMI 65% of patients completed treatment compared to only 45% in the control group. At 12 months the ETMI group also presented a better outcome in the primary outcome analysis, the RMDQ. Significantly more patients in the ETMI group at 84% achieved a reduction of more than 30% in disability scores from baseline versus the control group of only 64.2%. In the secondary outcome analysis the ETMI group also showed a significant improvement versus the control group in both lower ratings of worst pain and the SF-12 physical health summary, however the SF-12 mental health summary showed no significant differences between the groups. At the same 12 month point, the ETMI also had more patients be considered physically active at 58% compared to the control groups 44%.

Based on these results, authors have suggested that an intervention based on addressing patient specific obstacles to exercise may be more beneficial long term in reducing disability and increasing physical activity levels than standard physical therapy practice. However, they do caution the interpretation of these results at this stage, until they are further proven by future research

What conclusion can we take from this research?
This research has provided an alternative look into methods of treating chronic low back pain and includes promising results, suggesting there could be a more efficient treatment for those suffering from this condition. Targeting patients barriers to physical activity such as fear avoidance and self-efficacy and working to remove these barriers shows signs of being more effective than standard therapy in improving patient physical activity levels.

Adherence to both treatment programs was measured through self-reported data, bringing into question the reliability of the study due to the potential for personal bias' when reporting data.

Practical advice
This research indicates that physical therapy moving forwards may benefit from undergoing extra training in behavioural change techniques and incorporating them more in their treatment. More research should be done on why the ETMI method was more successful, as well as further exploration into the potential of a combination of the two styles providing even better results. As the authors state, more research should also be done to further support the conclusions made from these results. Further research should also objectively measure patient activity / participation in order to improve reliability as discussed in this paper. The authors suggested the use of accelerometers as one example.

Further information / resources
Causes of Lower Back Pain

Low Back Pain Fact Sheet

Chronic Low Back Pain - Physiopedia

What You Should Know About Low Back Pain