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Aerobic Exercise Training in Addition to Conventional Physiotherapy for Chronic Low Back Pain: A Randomized Controlled Trial
Carol W. Chan, PT, MSc, Nicola W. Mok, PT, PhD, Ella W. Yeung, PT, PhD
ABSTRACT. Chan CW, Mok NW, Yeung EW. Aerobic exercise training in addition to conventional physiotherapy for chronic low back pain: a randomized controlled trial. Arch Phys Med Rehabil 2011;92:1681-5.
Objective: To examine the effect of adding aerobic exercise to conventional physiotherapy treatment for patients with chronic low back pain (LBP) in reducing pain and disability. Design: Randomized controlled trial. Setting: A physiotherapy outpatient setting in Hong Kong. Participants: Patients with chronic LBP (Nϭ46) were recruited and randomly assigned to either a control (nϭ22) or an intervention (nϭ24) group. Interventions: An 8-week intervention; both groups received conventional physiotherapy with additional individually tailored aerobic exercise prescribed only to the intervention group. Main Outcome Measures: Visual analog pain scale, Aberdeen Low Back Pain Disability Scale, and physical fitness measurements were taken at baseline, 8 weeks, and 12 months from the commencement of the intervention. Multivariate analysis of variance was performed to examine betweengroup differences. Results: Both groups demonstrated a significant reduction in pain (PϽ.001) and an improvement in disability (PϽ.001) at 8 weeks and 12 months; however, no differences were observed between groups. There was no significant difference in LBP relapse at 12 months between the 2 groups (␹2ϭ2.30, Pϭ.13). Conclusions: The addition of aerobic training to conventional physiotherapy treatment did not enhance either short- or longterm improvement of pain and disability in patients with chronic LBP. Key Words: Exercise; Low back pain; Physical therapy modalities; Rehabilitation. © 2011 by the American Congress of Rehabilitation Medicine

LBP develops in 5% to 10% of persons with acute LBP,3 with pain persisting for more than 12 weeks. Chronic LBP is also a costly epidemic, with both direct health care and indirect costs (such as reduced productivity) imposed on the society. Notably, chronic LBP is associated with various physical, emotional, and psychosocial dysfunctions that eventually cause deterioration in the quality of life. Disuse and physical deconditioning are commonly evident in individuals with chronic LBP.4,5 In addition, “insufficient exercise” was acknowledged as a risk factor for the development of LBP.6 As such, exercise therapy for both primary and secondary prevention of LBP has been advocated as a priority research area. Exercise programs involve a mixture of training modes ranging from specific motor control exercise of the trunk muscles, strengthening, stretching, and/or aerobic training to more complex training programs.7-9 The isolated effect of aerobic exercise therapy has been examined in individuals with chronic LBP.10,11 The results revealed that aerobic exercise induced a short-term improvement in depression10,11 and a reduction of pain and disability10 in people with chronic LBP, when compared with electrotherapy to the lower back10 and a waiting list control.11 However, it has been argued that various exercise treatments could only cause a small but not clinically relevant change in people with chronic LBP when the effect of various exercise was studied alone.12 In view of the multiple problems within the biopsychosocial spectrum presented by people with chronic LBP, it has been suggested that a combined (rather than a single) treatment approach should be considered for contemporary clinical trials.13 The purpose of this study was to examine the effect of the addition of an 8-week, individually supervised, and progressive aerobic exercise program to conventional physiotherapy treatment for patients with chronic LBP. We tested the hypothesis that additional aerobic exercises would further improve physical fitness, pain, and disability in patients with chronic LBP. METHODS Participants Forty-six subjects (10 men, 36 women; mean age Ϯ SD, 46.0Ϯ10.2y) were recruited from the Department of Physiotherapy at the David Trench Rehabilitation Centre, Hong Kong. The progress of subjects through the randomized trial is presented in figure 1. Inclusion criteria included subjects with LBP symptoms for at least 12 weeks and declared medically fit to

OW BACK PAIN (LBP) is very common, and yet little is L known about its etiology or pathogenetic mechanism. The reported lifetime prevalence for LBP is as high as 84%. Chronic
1 2

From the Centre for Sports Training and Rehabilitation, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong. Presented in part to the Hong Kong Physiotherapy Association, December 8 –9, 2007, Hong Kong. Supported by the Department of Rehabilitation Sciences, Hong Kong Polytechnic University and Department of Physiotherapy, David Trench Rehabilitation Centre. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Trial Registration Number: ISRCTN23753357. Reprint requests to Ella W. Yeung, PT, PhD, Centre for Sports Training and Rehabilitation, Dept of Rehabilitation Sciences, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, e-mail: 0003-9993/11/9210-00403$36.00/0 doi:10.1016/j.apmr.2011.05.003

List of Abbreviations ALBPS LBP METs Aberdeen Low Back Pain Disability Scale low back pain metabolic equivalents

Arch Phys Med Rehabil Vol 92, October 2011

and back care advice (ergonomic principles. 3 times a week. Subjects were also instructed to perform at least 1 additional training at home each . nϭ22) or the intervention (aerobic training and conventional physiotherapy. passive segmental mobilization to the lumbar spine into end range.14 The target exercise heart rate was calculated by using the percentage of heart rate reserve method: (maximal heart rate – resting heart rate) (intensity fraction) ϩ resting heart rate. undertake physical fitness testing and exercise.1682 AEROBIC EXERCISE FOR CHRONIC LOW BACK PAIN.a The rating of perceived exertion (Borg CR-10 scale)16 was also used to provide a complementary estimation to exercise intensity. ultrasound. or inflammatory disease. October 2011 Aerobic Training Subjects in the intervention group received an additional aerobic training program for 8 weeks. CONSORT flow chart indicating flow of subjects through the trial. Arch Phys Med Rehabil Vol 92. including electrical modalities (interferential therapy. This duration was chosen to allow physiologic adaptations to aerobic training. or heat pack). abdominal stabilization exercise. Conventional Treatment Both groups received conventional physiotherapy treatments that are commonly used clinically for chronic LBP. To achieve the recommended aerobic improvement. and lifting techniques). Subjects were randomly allocated to the control (conventional physiotherapy. nϭ24) group. The choice of treatment was made by the physiotherapist based on the assessment findings. Abbreviation: VAS. systemic. or a workers’ compensation client.15 subjects performed 20 minutes of exercise. proper posture. visual analog scale. individually prescribed and supervised by a physiotherapist. Exclusion criteria included cardiac. Two training sessions were given and were supervised by the physiotherapist. The exercise intensity was set at 40% to 60% of heart rate reserve15 and gradually progressed up to 85%. back mobilization exercise. Subjects’ heart rates were monitored with a polar heart rate monitor. at a 5% increment each week. Chan Fig 1. All procedures were approved by the Institutional Medical Research Ethical Committee and were conducted in accordance with the Declaration of Helsinki. using a random number table concealed in sealed envelopes.

Data Analyses Intention-to-treat analysis was carried out for all analyses.8% of the subjects ranked below the 50th percentile for maximum oxygen consumption and body fat percentage.9 28. The Sorensen test for lumbar extensor endurance was performed with the subject holding the upper body unsupported in a horizontal prone position and the lower body fixed to the plinth. Arch Phys Med Rehabil Vol 92. maximum oxygen consumption. or cycling exercises.001).001. lower back and hamstring muscle flexibility.b The percentage of body fat was assessed by obtaining skinfold measurements of 3 sites (chest. triceps. jogging. not nerve root Below knee.2 to 16.5) 2 (9.2 39.0 to 5. At 8 weeks.1) 1 (4. Chan 1683 week. *Compared with baseline.0Ϯ15. stepping.6Ϯ14.05. significant improvements in pain and functional disability were reported in both groups (PϽ. Values are mean Ϯ SD or as otherwise indicated.4) 18. and 74% of the subjects had flexibility classified as fair to poor. The significance level was set at ␣ equal to .8Ϯ13.60Ϯ1. Improvements in disability were sustained in both groups at 12 months when compared with the baseline (PϽ.9 19. A mean of 486.9 34. Abbreviations: CI. This was defined as an LBP episode that required medical consultation after discharge from the study.0Ϯ9.7 2 (8.7 46.8Ϯ13.2) 10 (45.2) NA 3. Based on the American College of Sports Medicine’s age-adjusted standards.5Ϯ21. not tested.0 31.15 The first 2 stages were performed at 2.2) 7 (29. confidence interval.9) 23.5Ϯ13. Values are mean Ϯ SD.9* 19.0.1Ϯ8.3 59.5Ϯ13.5Ϯ21. or n (%).1Ϯ7. Aerobic capacity testing was performed according to the modified Bruce protocol on the treadmill. and (2) functional disability using a validated Chinese version of the Aberdeen Low Back Pain Disability Scale (ALBPS).7* NT 3.8Ϯ13.3%. The level of pain. The mode of exercise included treadmill walking/running. The third stage corresponds to the first stage of the standardized Bruce protocol.4Ϯ15. VO2max.3) 13 (54.5 30.0* NT 24.5 6 (27. Abbreviations: VAS.9 47.9) 4 (8. and thigh in men.9 28.5) 7 (31.5% and 47.001). October 2011 . the inclination was increased by 2% with a concomitant increase in speed.5 30.2Ϯ9. back extensor muscular endurance. The number of LBP relapses was also obtained.0Ϯ11.8Ϯ13. as preferred by the subject. NA.9Ϯ323.2) 3 (10.1Ϯ21.5Ϯ20. Most subjects (83.30 metabolic equivalents (METs) was performed at each session.74km/h at 0% and 5% grade. and thigh in women) with skinfold callipersc and by using the Siri equation.d Values are presented as mean Ϯ SD.15 An average of 35. The intervention Table 2: Pain and Disability Scores at 8 Weeks and 12 Months Follow-up Pain and Disability Scores Control (nϭ22) Baseline 8wk 12mo Baseline Intervention (nϭ24) 8wk 12mo Difference in Mean Change Scores (95% CI) at 8wk Difference in Mean Change Scores (95% CI) at 12mo Pain score (0–100) Disability score (0–100) 59.9 (Ϫ0. However.0Ϯ4.2* Ϫ0. Eighty-one percent (nϭ18) of the subjects chose walking. respectively. respectively.8Ϯ11.AEROBIC EXERCISE FOR CHRONIC LOW BACK PAIN.8Ϯ34. and percentage of body fat.3%) were able to reach the target intensity range of 50% to 85% HRR at the end of the 8-week intervention. the subjects were contacted by telephone and asked to complete the ALBPS. Table 1 presents the baseline demographic characteristics of the subjects.6 to 8. 43. NT.0 NOTE.5Ϯ21.5) NOTE.14 Outcome Measures The primary study outcomes were (1) pain measured with a 100-mm visual analog scale.7) 10 (45.0Ϯ12.9Ϯ7.1 minutes of aerobic exercises at 5.7) 13 (28. PϽ. visual analog scale.0 (Ϫ10.8) 5 (22.5 5/17 14.5Ϯ28.5) 9 (40.7 MET · min · wkϪ1 was accrued for subjects in the intervention group. Outcomes variables were compared across time by using analysis of variance for continuous variables and chi-square analysis for categorical variables.9 42. A multivariate analysis of variance test was performed to examine between-group differences.3 5/19 11. nerve root Physical activity (MET · min · wkϪ1) None: 0 Light: 1 to Ͻ450 Moderate: 450–750 Vigorous: Ͼ750 Physical fitness parameters Body fat percentage (%) VO2max (mL · kgϪ1 · minϪ1) Back extensor endurance (s) Sit-and-reach test (cm) Pain and disability scores Pain score VAS (mm) ALBPS score 46. Physical Fitness Measurements Physical fitness parameters included aerobic capacity. No significant differences were found between the Table 1: Baseline Characteristics of Subjects Baseline Characteristics Control (nϭ22) Intervention (nϭ24) Age (y) Men/women Duration of current symptom (mo) Recurrence of LBP Area of LBP Local LBP and above knee Below knee.22 (Ϫ6. The sit-and-reach test for flexibility was evaluated with the Flex-Tester.2) 24.1 22.1* 20.1 59. suprailiac. Seventy-seven percent of the subjects in the intervention group performed additional aerobic exercises at home for at least 30min/wk.4Ϯ6. ALBPS. n. and fitness parameters were measured at baseline and 8 weeks.8 40. Home exercise adherence was recorded by each subject on a log sheet. no significant differences were detected in pain and disability between the 2 groups at either time (table 2).1) 4 (16.7) 14 (52.1* 59. RESULTS There was an overall exercise attendance rate of 91. At 3-minute intervals. or running as the preferred mode of aerobic exercise training. not applicable.17 The secondary study outcomes were the physical fitness parameters. 2 groups.8Ϯ11. All analyses were conducted using the SPSS version 16. abdomen. At the 12-month follow-up.

5 which suggest the importance of aerobic exercise for chronic LBP.30.8Ϯ8.9 23.2Ϯ9.18 In this metaanalysis. The subjects may have benefited from a more intense exercise program of longer duration.7Ϯ2.04* . Van der Velde G. In this study.2Ϯ7. 8. In the metaanalysis that examined intervention characteristics that could improve outcomes for patients with chronic LBP. JAMA 1992.001* NOTE. making it difficult to identify long-term changes.001* 59.5 26. Second. The poor baseline fitness level is a major limiting factor in this study. What can the history and physical examination tell us about low back pain. Chi-square analysis revealed no significant difference between groups (␹2ϭ2.9 22.9 19. perhaps the loading stimulus is too small to result in noticeable effects on pain and disability. it was shown that individually designed and supervised exercise is more effective. Torgerson D. Deyo RA.19. the physiotherapist moniArch Phys Med Rehabil Vol 92.919:i-x.8 40.74 . The poor physical fitness level evident in our patients is consistent with the findings of previous studies. DISCUSSION This study investigated the effect of adding an aerobic exercise program to conventional physiotherapy in people with chronic LBP. back mobilization and abdominal stabilization exercise were included as conventional treatment.81:1457-63. Pϭ. There was significant short-term improvement in pain and disability in both groups. Arch Phys Med Rehabil 2000.1 58. Mierau D.24 . First.7 . Frymoyer JW. Vlaeyen JW. Verbunt JA. Bell-Syer S. World Health Organ Tech Rep Ser 2003. 6.9Ϯ7. and preferences. 5. maximum oxygen consumption. the addition of aerobic training to conventional physiotherapy treatment did not lead to improvement of pain and disability at the short.8Ϯ2. The lack of blinding of the outcome assessors to group allocation may result in bias. Moseley L. Rainville J.9 42. Randomised controlled trial of exercise for low back pain: clinical outcomes. BMJ 1999. Walker BF.4Ϯ6.4 22. the magnitude of change may be too small. We thank Raymond Cheung.3Ϯ5. 1-218.0 40.0Ϯ8.2 39. CONCLUSIONS The findings of this study revealed that in patients with chronic LBP. Aust J Physiother 2002.7:9-21. PhD. N Engl J Med 1988.3 59.8Ϯ34. In the long-term. there were no significant differences between groups for changes in physical fitness parameters (table 3). including abdominal stabilization exercise. Acknowledgment: tical advice.0 24. group improved in all physical fitness parameters. . our sample size was relatively small to detect significant improvements in outcomes.9Ϯ37. The burden of musculoskeletal conditions at the start of the new millennium.2Ϯ9.0Ϯ9. WHO Scientific Group on the Burden of Musculoskeletal Conditions at the Start of the New Millennium. in addition.2Ϯ8.319:279-83.8 40. The results indicated that the addition of supervised aerobic exercise training did not enhance the improvement in pain and disability. 4. They could learn to modify the exercises according to their fitness level and fluctuations in pain level. Kent DL. The aerobic exercise training had no adverse effects on the subjects. We opted not to measure pain at the 12-month follow-up because it has been acknowledged that fluctuation in pain level seems to be one of the characteristic features in chronic LBP.21 We consider the ongoing supervision from the physiotherapist as an integral part of an individualized exercise therapy intervention. Seelen HA.005* . 7.0 24. Chan Table 3: Physical Fitness Parameters Before and After 8-Week Intervention Control (nϭ22) Physical Fitness Parameters Baseline 8wk P Baseline Intervention (nϭ24) 8wk P Body weight (kg) Body mass index (kg/m2) Body fat percentage (%) VO2max (mL · kgϪ1 · minϪ1) Back extensor endurance (s) Sit-and-reach test (cm) 58. 2.7 46. Values are mean Ϯ SD or as otherwise indicated.1Ϯ27. increased frequency.48:297-302. changes in physical fitness parameters were not assessed at 12 months.02* .4 23.2Ϯ7. the nature of the aerobic exercise training made it impossible to conceal treatment allocation to the subjects or the investigators.4. Combined physiotherapy and education is efficacious for chronic low back pain.5 22.13:205-17. October 2011 tored the subjects’ adherence to the exercise training program. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998.5Ϯ28.5Ϯ9.02* .02* .4 .20 Thus. while the control group improved only in flexibility and percentage of body fat. et al. pain and self-rated disability in patients with chronic low back pain: a retrospective chart review.49Ϯ3.318: 291-300. Disuse and deconditioning in chronic low back pain: concepts and hypotheses on contributing mechanisms.13 . Moffett JK.0Ϯ4. Back pain and sciatica. as evidenced by the ability of most subjects to reach the target intensity range.and long-term follow-up beyond that achieved with conventional physiotherapy alone. et al.3Ϯ3.1 22. Study Limitations There are several limitations to consider in this study. seems to be slightly effective at pain reduction and functional improvement for chronic LBP. The effects of exercise on percentile rank aerobic capacity. the authors suggested that exercise therapy. In the present study. Abbreviation: VO2max. or both. Eur J Pain 2003.1 24.2 59.2Ϯ7. which might contribute to the improvement as evidenced by the improvement in pain and functional disability as well as flexibility (note: the sit-and-reach test requires lumbar spine mobility) in both groups.2Ϯ9. J Spinal Disord 2000. and their bodies’ response to the exercises.1684 AEROBIC EXERCISE FOR CHRONIC LOW BACK PAIN.268:760-5. However. 3.1Ϯ7. costs. Furthermore. which reaffirms the findings of the meta-analysis on exercise therapy for the management of LBP by Hayden et al.11 Ͻ. adherence might improve if the subjects become aware of the benefits of. Although the intervention group showed an improvement in all fitness parameters after 8 weeks. only ALBPS and the number of LBP relapses were assessed at the 12-month follow-up in this study.5 23.3 49. *Statistically significant. for statis- References 1. the intensity of pain is not associated with activity level in people with chronic LBP.13) in the incidents of LBP relapse at the 12-month follow-up.03* .

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