Low back pain impacts anywhere from 4 to 25% of the Canadian population. That is a huge number of people suffering daily, many relying on pharmaceutical solutions that are less than ideal. Chiropractic care has long been a tool to treat and prevent pain in the low back and the rest of the musculoskeletal system. The study below explores how education and prescriptive home care walking programs can help reduce low back pain recurrence.

BACKGROUND INFORMATION:
Low back pain (LBP) is highly prevalent and disabling. It is also pervasive for many, as we know that approximately 70% of individuals experience a recurrence of back pain within 12 months following recovery from an episode (1). Such recurrences contribute significantly to the overall burden of LBP, both on a personal disability level and economically at a societal level. Individuals with recurrences of LBP are known to experience longer work absenteeism and incur higher costs compared to those without recurrence.

Evidence-based and clinical guideline concordant care for LBP includes a multimodal approach, including manual therapy, exercise and education. The combination of education and exercise has been shown to reduce recurrence of LBP, associated disability and work absenteeism (2). However, much of the existing research on exercise has been focused on group-based programs that require clinician supervision and the use of equipment, all of which can result in high cost and a potential barrier to access for some patients.

Walking is a low risk, inexpensive and accessible activity for most people, regardless of socioeconomic status or geographic location. Walking delivers numerous health benefits, including improved cardiovascular health, enhanced cognition and mood and even reduced risk of non-communicable diseases (3, 4). Although these benefits are widely accepted, there is a paucity of research examining the potential benefit of walking for those with LBP.

The aim of this study was to investigate the clinical and cost effectiveness of an individualized, progressive walking and education program for preventing recurrences of LBP.

PERTINENT RESULTS:
701 adults, 81% of whom were female (average age was 54 years) participated in the study and were randomized to the intervention group (n = 351) or the control (n = 350). Participants reported a high perceived risk of recurrence and a high number of prior episodes of LBP, with a median value of 33 episodes. 96% were successfully followed-up until the minimum 12-month point. Baseline characteristics were well balanced between the intervention and control groups.

Walking volume in the intervention group was increased from an accumulated duration of 80 minutes in week 1 to 130 minutes by week 12, with a corresponding increase in number of times walking per week also increasing from 3 in week 1 to 4 in week 12.

The walking intervention reduced the risk of an activity-limiting recurrence of LBP compared to the control by 28% (HR 0.72 [95% CI 0.60-0.85], p=0.0002). The median number of days to recurrence in the intervention group was 208 days compared to 112 days in the control group. The walking intervention also reduced the risk of any recurrences of LBP and care-seeking recurrences of LBP by 20% and 43%, respectively in the first 12 months.

For secondary outcomes, disability and health-related quality of life favoured the intervention group at all time points, but the model assumptions were not met, so these results should be interpreted with caution. There were no significant differences noted for moderate/vigorous activity or sedentary time between groups.

The incremental cost per QALY gained was AU$7802, resulting in a 94% probability that the intervention was cost effective at a willingness-to-pay threshold of $28000.
A similar number of participants experienced adverse events (AEs) between the groups, but those in the intervention group reported a higher number of AEs related to the lower extremity (100 versus 54 in the control group).

CLINICAL APPLICATION & CONCLUSIONS:
The take home message from this study is simple, potentially powerful and applicable in every chiropractor’s office!

It may surprise you, but WalkBack is a world-first trial, demonstrating that an individualized, progressive walking and education intervention, compared with a no treatment control, can substantially reduce recurrences of LBP and associated care-seeking. The intervention also had a high probability of being cost-effective. Since walking is simple to add to existing care plans, accessible and low cost, this intervention has the potential of being implemented at scale.

If widely implemented in conjunction with manual therapy, advice and other evidence-based interventions, a simple walking program could enhance patient outcomes and proffer numerous secondary health benefits that come with any form of exercise – a win, win!

In your practice tomorrow, prescription of a walking program could become part of your discharge instructions, or something to integrate after a few treatments, when the patient’s pain is hopefully improving. Get your patients moving and while they are out walking, they’ll tell everyone they see how amazing their chiropractor is!

STUDY METHODS:
This trial, named “WalkBack”, was conducted as a two-armed, randomized trial. Adults 18 years of age and older were recruited from 25 private physiotherapy clinics across Australia who had recently recovered from an episode of non-specific low back pain. These episodes were further defined as follows:
• LBP not attributed to a specific diagnosis
• Episode lasted for at least 24 hours
• Scored at least 2 on a 0-10 numeric pain rating scale
• Causing at least somewhat or greater interference with day-to-day activities (measured on an adopted version of item PI9 of the PROMIS item bank: “How much did low back pain interfere with your day-to-day activities” – not at all, a little bit, somewhat, quite a bit, very much)

Recovery from the episode was defined as more than 7 consecutive days with pain no greater than 1 on a 0-10 NPRS. Exclusion criteria:
• Any comorbidity preventing participation in a walking program
• Current walking for exercise 3+ times per week (30 or more minutes per day)
• Current regular participation in an exercise program for the prevention of back pain (ex. Pilates)
• Achieving more than 150 minutes of moderate/vigorous activity weekly (across a minimum of 3 days per week)
• Spinal surgery in the preceding 6 months
• Current pregnancy
• Inadequate level of English to complete study questionnaires

Subjects were randomly assigned to an individualized, progressive walking and education program facilitated via six sessions with a physiotherapist over 6 months, or to a no treatment control group in a 1:1 ratio. Both subjects and the physiotherapists were not able to be blinded to the group allocation. The first 5 sessions occurred within three months of randomization, with the sixth session acting as a booster at six months.

Intervention:
Physiotherapists used a health coaching approach to support an individualized and progressive walking program, structured to optimize long-term adherence. A general guide for the program was to walk 5 times per week for at least 30 minutes daily by 6 months. Importantly, a person-centered approach was used whereby the clinicians tailored the program via discussion with the individual and consideration of their personal factors (ex. comorbidities and self-efficacy), environmental barriers (ex. safety, lighting or surfaces), time constraints, preferences and their personal goals. Each subject was given a pedometer/accelerometer to measure their steps. Education was provided alongside the walking program, aiming to provide basic pain science information and reduce fear associated with LBP. Participants in both groups were not restricted from seeking other care for their LBP as required.

Outcomes & Follow-up:
Subjects were followed for a period of 12 months (minimum) up to 36 months. The primary outcome of interest was the number of days to the first occurrence of an activity-limiting episode of LBP. This information was gathered in monthly self-report. Cost effectiveness was evaluated from a societal perspective as incremental cost per quality-adjusted life year (QALY) gained.
Secondary outcomes were collected at 3,6, 9 and 12 months and included:
• Roland-Morris Disability Questionnaire (RMDQ)
• Health-related quality of life (EuroQoL EQ-5D-5L)
• Physical activity and sedentary behavior (using an Australian version of an international physical activity questionnaire)
• Adverse events and serious events (self-reported)

If you would like to book an appointment with one of our chiropractors, please email us at info@evolvevancouver.ca. You can also book an appointment with Dr. Neeta Basra online

Please note that any advice in this article doesn’t replace personalized medical advice from a professional.

STUDY STRENGTHS / WEAKNESSES:

Strengths:

  • This trial was prospectively registered, and the protocol was published.
  • Excellent follow-up rates were obtained, strengthening the data.
  • The trial featured subjects with a significant history of LBP episodes on average, representing a problematic patient population we all see in practice.

Weaknesses:

  • Subjects and clinicians could not be blinded to the intervention.
  • Most participants were female and between the ages of 43 and 66, which may limit generalizability (despite being a group that experiences back pain!)
  • Data pertaining to ethnicity was not collected.

AUTHOR’S AFFILIATIONS:
Department of Health Sciences and Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, and School of Mathematical and Physical Sciences, Macquarie University, Sydney, Australia; The Institute for Musculoskeletal Health, Sydney Local Health District, Australia; Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Australia; Department of Health Sciences, Vrije University of Amsterdam, Amsterdam, Netherlands.

PUBLICATION INFORMATION:
Lancet 2024 Jun 19: S0140-6736(24)00755-4. doi: 10.1016/S0140-6736(24)00755-4.

Additional References
1 da Silva T, Mills K, Brown BT, et al. Recurrence of low back pain is common: a prospective inception cohort study. J Physiother 2019; 65: 159.165.

2 de Campos TF, Maher CG, Fuller JT, Steffens D, Attwell S, Hancock MJ. Prevention strategies to reduce future impact of low back pain: a systematic review and meta-analysis. Br J Sports Med 2021; 55: 468–76.

3 Hanson S, Jones A. Is there evidence that walking groups have health benefits? A systematic review and meta-analysis. Br J Sports Med 2015; 49: 710–15.

4 Kelly P, Williamson C, Niven AG, Hunter R, Mutrie N, Richards J. Walking on sunshine: scoping review of the evidence for walking and mental health. Br J Sports Med 2018; 52: 800–06.