Increasing Recreational Physical Activity in Patients With CLBP

[Michael McMurray]

Hi everyone, here is the citation for the journal article for this month’s discussion:

Ben-Ami N, Chodick G, Mirovsky Y, Pincus T, Shapiro Y. Increasing Recreational Physical Activity in Patients With Chronic Low Back Pain: A Pragmatic Controlled Clinical Trial. J Orthop Sports Phys Ther. 2017;47(2):57-66. doi:10.2519/jospt.2017.7057.

This article resonated with me as I see many patients with chronic low back pain (CLBP) in the clinic. Over the last several months, I have started to inquire more about a patient’s activity level in their initial evaluation as well as subsequent visits. Additionally, trying to discuss and implement recreational activity as a part of treatment with most patients, but particularly this subset.

So, here’s my review on the article:

The article introduces the challenges of increasing physical and recreational activity in patients with CLBP. Previous trials which have tried to do so have concluded the need to address underlying obstacles that result in small patient improvement with little long term carryover. The goal of this study was to incorporate and determine the effectiveness of an enhanced transtheoretical model intervention (ETMI) in increasing the level of physical activity in those with CLBP as compared to traditional physical therapy alone. The study used this model to determine a participant’s perception of their readiness to change in order to provide them with the tools and strategies needed to increase participation in physical activity.

Out of 220 eligible participants, 189 completed the study. Inclusionary criteria included participants between the ages of 22 and 55 years old, who had greater than three months’ duration of low back pain with or without radiating symptoms into a lower limb. Exclusionary criteria included those with rheumatic diseases, tumors, fractures, fibromyalgia, previous spinal surgeries, pregnancy, and pain following automobile or work accident.

Participants in the EMTI group had therapy focused on the obstacles they faced when attempting to start recreational activity, including low esteem, motivation, and fear of movement. Their principle intervention was to determine a recreational activity which they could perform at a “moderate level.” Also, therapist addressed fear of movement with graded activity. The ETMI group did not receive other mainstream forms of therapy including mobilization, manipulation, modalities, and postural education. Lastly, ETMI group members received advise on how to respond to an acute low back pain episode.

The physical therapy control group received traditional interventions as well as the back exercises available to ETMI group members if appropriate.

Baseline measurements for all participants included Roland-Morris Disability Questionnaire (RMDQ) scores, pain intensity, duration of low back pain, SF-12, and levels of physical activity. ETMI group participants were classified on the stage of readiness for change at the beginning and end of treatment. Stages include precontemplation, comptemplation, preparation, action, and maintenance. Follow up measurements were taken at three and 12 months.

Here are some of the results:

65 percent of the EMTI treatment group compared to 45 percent of the control group completed treatment. EMTI participants completed 3.5±1.9 sessions; whereas, those in the control group attended 5.1±3.4 sessions. On the primary outcome measure, those in the ETMI group had statistically significant improvements in disability (RMDQ measurement) as compared to the control group. This difference was more than 2.5 which indicates a clinically meaningful change in disability. Secondary outcome measures show there was no significant difference at three months, but significant differences in pain rating, SF-12 physical health summary score, and level of physical activity between groups at the12 month mark.

This study found that while both groups showed a short term increase in physical activity and long term decrease in disability and pain for participants, results were better in the ETMI group. This may suggest that identifying and addressing obstacles preventing those with CLBP to participate physical activity may be more beneficial to reduce pain and disability than traditional physical therapy care.

Points of discussion:

1. I thought it was interesting that they excluded patients over 65 because they failed to find significant differences between groups in previous studies. Many of the patients I have are close to or fit in this population group. Do you still see reason to use this type or approach with these patients?

2. They discussed fear avoidance and low self-efficacy as obstacles to engaging in physical therapy, however, they did not utilize any outcome to measure this. How do you measure these types of obstacles in the clinic?

3. How do you get patients who have chronic low back pain to buy-in on incorporating recreational exercise, especially with those who may have fear of movement and fear avoidance behaviors? Do you use a graded activity or exposure style approach?

4. I have been trying to ask more questions while performing evaluations to get a picture of what people do for recreational activity. How and when do you address what a patient does for recreational activity? How do you bring this up with patients who seem reluctant?

5. If you have a patient in one of the categories (precontemplative, contemplative, etc.), what are some strategies you may utilize to move them forward on this schema?

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[August Winter]

Katie, love the article as I think that we should be promoters of PA for all of our patients in order to reduce pain and in a big picture, attempt to reduce all cause mortality and morbidity.

1. I think this article nicely provides a framework to use the TTM for addressing PA for all patients. If the previous study was set up like the current one, then the comparison was made between a normal PT care control group and a hands off experimental group in patients 65 and older. Obviously this is not really how we practice in the clinic, so I think using this framework is still a valid adjunct to our normal care, even if the data wasn’t overwhelming.

What I found curious about the exclusion criteria was the lack of screening for depression. Individuals with depression have lower PA self efficacy and levels of leisure time PA, and there very well could have been differences between the groups that would have affected the results.

The exclusion of individuals with fibromyalgia (a quarter of my LBP patients) and following work or car accidents (another quarter of my LBP patients) hurts the ecological validity of this study.

2. For fear avoidance, you could use any number of different metrics we have already discussed, possibly even the FACS (shoutout to the October article discussion thread). I’ve never heard of using a specific self efficacy metric in the clinic, as I feel like the domains of many fear avoidance questionnaires hit upon self efficacy. Looking at a recent article in the Journal of Bodywork and Movement Therapies, the Pain Self-Efficacy Questionnaire can be used.

3. Depending upon the patient’s education level, I might discuss the analgesic effects of regular physical activity. Depending on what level of activity they are currently doing, I typically try to set goals for activity within the next week for a certain number of minutes doing something active, even if it is a low MET activity.

4+5. I typically will ask during the evaluation what sort of regular activity they do, and if they don’t engage in regular PA, I ask if they have a desire to or not. I think this heavily frames my approach from there. If someone wants to be more active but is fear avoidant or has low self efficacy, I definitely try to bring it back to their goals during the evaluation. If someone has no desire to be active I typically introduce the idea that PT involves exercise. If we can even start with that I will continue to try to discuss the benefits of PA overall and for pain. In briefly mentioning the stages in the article, I like that for the contemplative phase it discusses bringing about how this change might affect others. I think this can be pretty powerful for a lot of patients in getting them to move further into the preparation stage.

What struck me about this article was for the BPAQ they highlighted the difference between the two groups, but I’m not sure if they ever mentioned what a meaningful improvement actually was? At 3 mo the experimental group only increased 0.2, does that actually matter?

[Erik Lineberry]

1. I agree with you, I find it hard to believe that this group of patients would not have a significant change. This is definitely a large a part of my current practice too and anecdotally, I have found benefit in addressing activity level and encouraging increased activity in older adults with CLBP.

2. FABQ or STaRT. I should probably look to diversify.

3. I think graded exposure is the way to go. I talk up any aerobic activity early and often with most patient’s, but probably more so with patients with CLBP.

-My little soapbox speech goes something like this, “The best CV/general exercise for you is something that you will do regularly, so if you like walking, biking, swimming, group exercise, badminton, etc. do it. Getting your heart rate up will increase blood flow and healing throughout your body, decrease your pain, and increase your feel-good hormones. That’s 3 good things for you right now and in the future, so finding something you will make a habit of is important” I change it up based on the person, but that’s the just of it and I have found that it works with most folks.

4. I always ask “what would you be doing if X body part/region wasn’t hurt” or “what did you like to do before your injury? if they are having a hard time answering “what do you do for fun/exercise”. I have found pretty good success with that, but I still get the occasional patient that states they do nothing or just watch TV.

5. I like asking questions based on the patient’s perspectives to help get the patient to start thinking about what they want out of PT and to motivate them.

[Scott Resetar]

1. Agree with what others have said. I think another reason the researchers may have wanted to exclude this group is due to ceiling effects. We may not expect a 65+ year old to have as much functional improvement as a 45 year old, and disability measures used here are sometimes correllated to working status, and this group is much more likely to not be working, either due to retirement or health reasons.

2. I love the FABQ, obviously, but it isn’t perfect. Often I will have a patient that subjectively seems very low fear, and then their FABQ is very high, or vice versa, and this can be hard to discern their true level of fear. I like the pain self efficacy scale that August mentioned as well. I have attached an article from European journal of pain that goes through close to 20 years of research on this measure.

3. Graded activity for sure. Ease into it! I ask about what they feel they can tolerate .. i.e. how many minutes do you feel you could walk without an increase in your symptoms. Take the number they give you and divide by 2, and start there.

4. I ask this in every evaluation, rather early, in my social history. Occupation, marital status, children, their ages, activity level. I am going to talk differently about exercise to a 40 year old female who exercises 5x a week with friends in different exercise classes vs a 40 year old female who has never exercised. This also can change my subjective questioning (does it hurt during classes? have you ceased classes because of this?)

5. I usually go the cheerleader route. I can point them to exercise-only self pay sessions at our clinic, the YMCA right next to our clinic, or a physician referred exercise program at the ACAC (gym) near us. I will often recommend they join their local gym and then have 1-2 f/u visits at our clinic to discuss how the transition is going, trouble with certain exercise machines, etc.

FYI, YMCAs usually have some sort of “medical liason” who you can speak with to discuss your patient (after signed HIPAA disclosure form), their history, what machines may be beneficial. We recently did this with a few patients, and it really helped smooth the transition.

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