Effective Recovery and Control of Chronic Low Back Pain by using Rehabilitation Exercises Therapy

 

Qais Gasibat1*, Malak Hasan Mesrati2 , Rabiu Muazu Musa3, Ahlam A. Zidan4

1Faculty of Medical Technology, Physiotherapy Department, Misurata, Libya

2School of Science and Engineering, Malaysia University of Science and Technology, Encorp Strand Garden Office Kota Damansara, Kuala Lumpur, Malaysia

3Faculty of Applied Social Sciences, Universiti Sultan Zainal Abidin, Gong Badak Campus, Kuala Terengganu,Terengganu, Malaysia

4Physiotherapy Department, College of Medical Technology, Az-Zawia University, Az-Zawia, Libya

*Corresponding Author E-mail: drqaiss9@gmail.com

 

ABSTRACT:

Exercise is a commonly recommended treatment for chronic low back pain due to its effectiveness in enhancing work and function. This study aims to review numerous crucial phases of the usefulness and safety of exercise in order to provide vital information for treating chronic low back pain. An online literature search of Medline was performed using “exercise,” “fitness,” “low back pain,” “backache” and “rehabilitation” as search words. Abstracts that identified using this method were carefully read, and relevant articles were considered for further analysis. Additional materials were gathered by sourcing relevant research articles. The articles were carefully examined for relevance. There is no evidence that exercise increases low back pain problems, particularly for people with acute, subacute or chronic low back pain. Current studies indicate that exercise has either a neutral effect or might reduce the risk of future back injuries to some extent. Exercise might be suggested for patients with chronic low back pain for three purposes. The first and most recognized purpose is to enhance or decrease deficiencies in back flexibility and strength and improve the performance of endurance activities. It is evident that this purpose can be achieved for most patients suffering from chronic low back pain. The second purpose of exercise is to decrease the severity of low back pain. Many studies reported an overall decrease in the intensity of low back pain ranging from 10% to 50% subsequent to exercise treatment. The third purpose of the exercise is to decrease low back pain–related incapacity by desensitizing worries and anxieties and changing pain attitudes and beliefs. The exercise mechanisms that can be employed to achieve the aforementioned purposes have been the subject of extensive study. The relevance of using exercise as a therapeutic method to decrease deficiencies in back flexibility and strength has been established. Several studies reported enhancements in global pain ratings subsequent to exercise programs. Exercise can also reduce the cognitive, behavioral, and disability effects of low back pain conditions.

 

KEYWORDS: Exercise; Low Back Pain; Rehabilitation.

 

 


 

I. INTRODUCTION:

There has been a growing interest in exercise for the treatment of low back pain over the past few decades. This has stimulated a systematic review of evidence regarding the usefulness of exercise. It is therefore concluded that exercise can be useful for patients who have chronic low back pain1. This paper reviews various crucial facets of exercise that might be valuable for clinicians who wish to suggest exercise as a treatment option for patients with chronic low back pain. First, the safety of exercise is reviewed, particularly its effectiveness in reducing the risk of additional pain, disability, or injury. Then, clinical usage of exercise is suggested to be viewed based on three different, though correlated objectives: 1) improving decreased back function; 2) reducing symptoms; especially related to low back pain and 3) reducing disability through eliminating extreme fears and worries about low back pain. This might provide valuable information to enhance clinicians’ understanding of the rationale behind the use of exercise as a treatment for chronic low back pain. It is also hoped that the use of exercise as treatment for low back pain will be improved1.

 

II. EXERCISE AND THE RISK OF LOW BACK PAIN:

In view of any therapeutic modality, risks and benefits of the alternative treatments must be considered. The major risk with exercise is the possibility of triggering low back pain or spinal degeneration. Some individuals might experience low back pain during or subsequent to exercise. To ascertain whether exercise puts individuals at high or increased risks during or after exercise, it is imperative to determine the degree of low back pain incidents in those who perform regular exercises compared to those who do not perform exercises.

 

A number of epidemiological studies were conducted to determine the incidences of fitness-related low back pain. For instance, Suni et al examined fitness-related low back pain in 498 adults2. The study revealed that low back pain and dysfunction were associated with low levels of back fitness, while improved back health is associated with high fitness. It was found in a 25-year prospective observational study that those who performed a minimum of least 3 hours of exercise weekly had a lower lifetime risk of low back pain. Physical exercise among 640 school children was examined in the study. Croft et al also performed a prospective study to examine 2,715 adults who did not have any low back pain4. The study revealed that excessive physical activity in a leisure-period does not trigger the 1-year risk of low back pain. It was also found that low physical health results in the risk of different low back pain incidents.

 

Videman et al. also found that low back pain is less prevalent among selected former athletes compared with controls and that low back pain incidents occurred with equal frequency5. For low back pain symptoms, another study compared a total of 2,000 employees without low back pain with 327 employees with low back pain for a period of one year. The results showed that exercise had no effect on low back pain6. In fact, these studies indicated that exercise does not generally trigger the risk of low back pain; rather, it may essentially have a protective effect against low back pain to some extent.

Since exercise does not generally increase low back pain risks, it is likely that people who perform regular exercise with low back pain can be reasonably safe, without having increased risks of further pain or injury. The positive health effects of exercise can generally provide significant benefit to individuals with low back pain7. It would also be encouraging if people with low back pain history benefited from regular exercise through decreasing the risk of future pain incidents. The effect of regular exercise on reducing low back pain and work-related absence due to low back pain has fortunately received the attention of some studies.

 

The effect of exercise on reducing the severity of low back pain has been determined by several researchers, and many studies revealed positive results regarding this issue. Hides et al. conducted a study to examine 39 patients with acute low back pain8. The results confirmed a reasonable immediate and continuous reduction in low back pain incidents. The study used a randomly selected group of participants for treatment using particular spine stabilization exercises in comparison with a control group. Moffett et al. also established significantly fewer sick days at follow-up for a one-year period. The author selected a group of participants with low back pain for a stretching exercise program compared with traditional specialist management.9

 

Soukup et al. randomly selected a group of 77 patients who had undergone treatment for low back pain10. The patients then undertook 20 sessions of exercises comprising pelvic, hip and abdominal exercises. The results showed that there was a significant decrease in persistent low back pain incidents at a 12-month follow-up. However, no changes in the subsequent sick leave of absence were noticed. Regarding subacute, persistent and chronic low back pain, certain studies proposed that exercise might reduce low back pain and work absence. Lindstrom et al. examined people sick-listed with subacute low back pain and reported that those who participated in the exercise program took less sick leave caused by low back pain in comparison with the control group11. Donchin et al. also examined low back pain in 142 hospital personnel reporting three annual low back pain incidents12. The personnel were randomized into three-month exercise groups and a control group. It was found that the exercise group had significantly less “painful months” compared with the control group at one year. Taimela et al. assessed 125 subjects with chronic low back pain for 14 months subsequent to a 12-week program for low back pain rehabilitation13. The results indicated that chronic pain recurrences occurred less commonly among subjects who performed regular exercise after the rehabilitation program than among those who had been inactive. The results also confirmed less work absence among the physically active subjects. It was observed that people with the best rehabilitation results were more likely to uphold exercise.

 

Some studies have reported the influence of a lack of exercise on chronic low back pain or work absenteeism. For instance, Dettori’s study revealed no changes in the recurrence rate among people with chronic low back pain for a period of 6-12 months subsequent to treatment, irrespective of extension or randomization of exercise groups for 8 weeks14. Faas et al. found that exercise treatment for patients having chronic low back pain did not decrease sick leave absenteeism15, 16. Bendix et al. also compared chronic low back pain patients who undertook a 39-hour rigorous physical training weekly for the duration of 3 weeks with those who had rigorous physical training at 1.5 hours three times weekly for the 8 weeks17. The study found no changes in sick leave of absence at one-year follow-up. Bentsen et al. examined 74 females with chronic low back pain who participated either in an active strengthening exercise program or a home training program18. It was found that adherence to exercise improved the overseen training, but no changes were found in sick leave days for both groups at a three-year follow-up.

 

In summary, studies have not provided a clear cut and definite evidence that exercise increases the risk of further low back pain incidents for individuals with subacute, acute or chronic low back pain. In this regard, the contemporary medical literature indicates that exercise has either a neutral or an insignificant possibly beneficial effect on the aforementioned risk. Therefore, it is evident that exercise is harmless for individuals with low back pain. Studies determined and justified the potential benefits of exercise in chronic low back pain treatment. These studies on the relationship between exercise and low back pain risk are summarized in  Table 1.


 

Table 1 Evidence concerning exercise and the risk of Low back pain

Study

Subjects

Outcome

Conclusion

Asymptomatic

Suni et al.2

498 middle-aged adults

Level of fitness and back health

High fitness was related to back health

Harreby et al.3

640 38-year-old adults, previously surveyed at age 14 years

Weekly exercise frequency and prevalence of  low back pain

Weekly exercise frequency 3 hours per week of physical activities reduced the prevalence of low back pain

Croft et al.4

2,715 adults without current low back pain

New low back pain episodes during year after health survey

Physical leisure-time activities not associated with short-term risk of low back pain

Viderman et al.5

937 former elite athletes and 620 controls

History of low back pain and sciatica

Low back pain was less common among athletes than controls

Miranda et al.6

7,000 forest industry workers

Survey of work and Physical exercise predictor and 1-year incidence of sciatica.

Physical exercise and most sports activities had no effect on sciatica

Acute low back pain Hides et al.8

39 adults with low back pain randomized to stabilization exercises versus control

Treatment

Recurrence rate of low back pain

2-year recurrence rates 35% for spinal stabilization group versus 75% for controls

Moffett et al.9

187 adults with low back pain randomized to progressive exercise versus control

Treatment

Disability, low back pain, work loss, medical care

At 1 year, exercise group had less disability, low back pain, work absence and medical car

Soukup et al.10

 

 

77 adults with low  pain randomized to exercise versus control treatment

Recurrence rate of low back pain

At 1 year, recurrence rate was 32% for the exercise versus 57% for the control group

Dettorri et al.14

149 soldiers with low back pain were randomized to flexion exercises, extension exercises or a control group

Recurrence of low back pain 6–12 months after entry

Similar recurrence rates were noted for each group

Faas et al.15, 16

473 adults with low back pain randomized to exercise, placebo ultrasound or control groups

Recurrence rate for low back pain and sickness absence from work

No differences in recurrence rates or work absence were noted

Subacute, recurrent or chronic low back pain Lindstrom et al11.

103 workers with low back pain were randomized into a graded exercise versus control group

Low back pain–related sick leave at 2-year follow-up

Work absence during second follow-up year was 12.1 weeks for the exercise versus 19.6 weeks for the controls

Donchin et al.12

142 workers with recurrent low back pain were randomized to calisthenics, back school or control groups

Painful months during 1-year follow-up period

Calisthenics group average 4.5 painful months versus 7.3 and 7.4 for the back school and control groups

Taimela et al.13

125 adults with chronic low back pain treated with 12-week exercise program

Exercise compliance and recurrence rates for low back pain at 1-year follow-up

Those that continued to exercise experienced fewer recurrences than those who were physically inactive

Bendix et al.17

138 adults with low back pain randomized to functional restoration versus less intense

physical training

Sick leave at 1 year

No difference noted between groups

Bentsen et al.18

74 57-year-old women with chronic low back pain were randomized to dynamic strengthening in fitness center versus home exercise

Disability, sick leave and pain at 3-year follow-up

No differences were noted between groups

 

 


III. EXERCISE AS A TOOL FOR IMPROVING BACK FUNCTION:

Exercise can be beneficial for improving back function in patients with low back pain since the clearest usefulness of exercise is its ability to enhance or maintain cardiovascular and musculoskeletal functions. In this regard, rehabilitation programs for low back pain are naturally intended to strengthen the back and improve back flexibility and cardiovascular fitness. This emphasis resulted from studies demonstrating that injuries of trunk strength19,22, flexibility23,25 and endurance26 exist in most individuals with chronic low back pain. These injuries cause part of the long-term movement inhibition and physical inactivity that can lead to physiological and neurological changes in the back. These changes consist of the paraspinal musculature weakness, with selective loss of Type 2 muscle fibers22, alteration of the relaxation response of the paraspinal musculature related to full flexibility of spine27 and restriction of muscles and connective tissues of the spinal area. This movement and activity restriction is mainly intentional, as individuals restrict activities that encourage low back pain both consciously and unconsciously or avoid them completely for fear of creating harm or injury27. Inhibition of movements and activities mostly starts early during low back pain and can be strengthened by health-care personnel by advising the patients to shun movements and activities that trigger pain28. These back function problems can be addressed by means of established exercise programs.

 

IV. EXERCISE FOR IMPROVING IMPAIRED flEXIBILITY:

Stretching exercises are useful in improving impaired flexibility. Nevertheless, it is necessity to perform stretching at the patient’s physiological end range, which should be within the motion range that is likely to prompt back discomfort. Stretching around the discomfort area is harmless and suitable for patients when their health-care personnel advise them professionally. Precise evaluation of trunk flexibility is useful in detecting injuries and observing improvement. Beneficial motions to evaluate consist of extension side bending and lumbosacral flexion.

 

Various methods for evaluating trunk motion range are accessible for medical personnel. The most precise measurements are found using double inclinometers19. This method makes the measurement of total lumbosacral motion possible, together with its pelvic and lumbar mechanisms. An easier substitute employs one inclinometer positioned on the T12-L1 interspace and evaluating total lumbosacral motion alone28. This technique has been found to be reliable and valid. For complete lumbosacral motion, the usual standards for trunk flexion (100-120 degrees), extension (25-45 degrees) and side bending (25-45 degrees) have been proven19,24. An inclinometer can be used to measure straight leg raising by taking it on the tibial tuberosity while inactively raising the leg until leg or low back pain follows significantly or pelvis rotation is witnessed. In this regard, 75-85 degrees are the standard values for straight leg raising19,24, and observed development can offer significant responses on efficiency to the patients and health personnel. Thus, flexibility quantification can be performed at a preliminary stage of evaluation, after every few treatment periods and at discharge.

 

There are several available techniques for stretching. Nevertheless, ballistic stretching is not usually suggested as this triggers muscle spindle reflexes that are counterproductive for increasing the length of muscles. The effectiveness of proprioceptive neuromuscular facilitation techniques has been confirmed, but they are not practical for independent home programs, and they require a qualified therapist. Static stretching is recognized as an effective method for enhancing flexibility as it simply requires a minimal level of training and can be performed without the presence of any therapist. This kind of stretching requires a minimum of 30 seconds to increase flexibility. It can be performed repeatedly up to four times for further benefits. Stretching at least three sessions per week enhances flexibility, but it provides even more flexibility improvements when performed five times per week. A single session of stretching per week is sufficient to maintain the improvements subsequent to increasing the flexibility through an exercise program.

 

Stretching exercises are expected to focus on the six lumbar motion directions that include flexion, extension, rotation to the right and left, and side bending to the right and left. In addition, it is emphasized that stretching should be done to improve the length of hip flexors, extensors, rotators, hamstrings, quadriceps and calves, as well as adductors and abductors. Numerous studies have recognized the effectiveness of stretching to enhance trunk flexibility in patients with chronic low back pain, with typical improvement of approximately 20%11,19,25,29,32. This indicates that long-term observance of a therapeutic stretching procedure has been fully documented7.

 

V. EXERCISE WITH THE GOAL OF IMPROVING IMPAIRED BACK STRENGTH:

A number of programs support strength exercise to improve flexibility. This is because many studies have demonstrated that trunk muscles of healthy individuals are stronger than those of patients who have chronic low back pain19,22. Resistance-training is mostly observed in the form of using exercise to develop lumbar extension. There are several factors for determining the effectiveness of resistance-training in enhancing adaptation trunk musculature, which include volume, mode, load, and frequency of exercise.

 

Many researchers have reported different resistance-training methods. Some of them suggest isoinertial resistive training on equipment that is specifically established20,21,33,38. This has to do with support for the use of equipment that separates the spinal musculature and removes pelvic motion through fixing the pelvis 20,21,33,38. Meanwhile, others support more involvement of pelvic motion for flexibility13,19,22,39,40. Isoinertial exercise equipment for resistance-training is advantageous as its performance level is continuously quantified, thus giving constant feedback regarding the progress objectives of the treatment.

 

At least 8-12 repetition maximum (RM) performances are suggested for optimum strength training of deconditioned people using isoinertial exercises21,37,41,42. Training less than the RM might be useful for decreasing worries and voluntary inhibitions during initial training sessions. However, it does not result in enhancement of strength and hence should be restricted to a few sessions. Strength training frequency has been examined, but no changes were discovered in one versus three times37 or two versus three times per week42. Presently, the programs suggested once38 or twice per week for most people20,21,34,36,42,44 with higher frequency of strength training and disabled workers19,22,31,32,45 as well as those who require higher strength levels including athletes42.

Some studies observed 30%-80% of volitional muscle strength enhancement during these programs19,22,30,32,34,36,43. Maintenance of strength in the lumbar extensor has been confirmed with weekly38 or even monthly exercise33. Certain researchers have recommended strength training using body weight as resistance. There are several potential techniques such as the use of an exercise ball or simple floor exercises. In other techniques, the upper or lower part of the body is static or maintained on a table or platform, while other parts of the body are raised or suspended from the platform side using trunk muscle strength46,48. It is difficult to precisely quantify strength in most of these forms of exercise, though enhancements in the performance quality and amount of repetitions are usually observed by patients and therapists. Additionally, the possible benefits of strength improvement have received partial documentation. However, measurements of improvement for trunk suspension training in the duration of capability to perform a lumbar isometric hold have been documented to a large extent46,49

 

VI. EXERCISE WITH THE GOAL OF IMPROVING CARDIOVASCULAR ENDURANCE:

Certain people who suffer from chronic low back pain demonstrate a reduced aerobic ability compared with healthy people26. Regarding strength and flexibility, cardiovascular performance is significantly affected by increases in pain severity related to activity during testing50. Hence, poor performance might not show the actual deficiencies in cardiovascular function50,51. Enhancing endurance is a practical objective of exercise for individuals with low back pain, irrespective of the reason for reduced performance.

 

Patients can increase cardiovascular endurance through several exercises that are performed for a long-term period at a submaximal level. The exercises may include cycling, use of treadmills, running, walking, dance, and swimming. A frequency of training at least three times per week26,52,53 for 15 minutes at 75% of the maximum heart rate has been proven to be effective in increasing endurance52. Increases in performance for activities of endurance have been confirmed after endurance training in patients who have low back pain25,26,31,54,55.

 

VII. EXERCISE AS A MODALITY TO REDUCE CHRONIC LOW BACK PAIN SYMPTOMS:

The use of exercise may reduce low back pain intensity, hence leading to low back pain treatment. Many uncontrolled and observational studies have observed this effect. These studies are summarized in Table 2. Most of these studies reported a positive effect from exercise programs for low back pain using different types of exercise. Frost et al. observed that an active exercise program comprising eight times in four weeks is better than unverified home exercise for decreasing pain (38% in the exercise group against 13% in the home exercise group)56. Torstensen et al. compared an active graded exercise program consisting of three weekly sessions for 12 weeks with conventional physical therapy and an unsupervised walking program. The authors discovered a 30% pain decrease in the active exercise group against a 23% pain decrease in the physical treatment group and a 9% pain decrease in the walking group after the treatment57.

 

Alaranta et al. also selected 378 participants with low back pain for less than six months and considerable work absences for a three-week active rehabilitation program58. The program involved rigorous exercise with behavioral and educational support or a controlled group that had inactive physical treatment and low-intensity exercises. Those who participated in the intensive exercise reported a significantly higher (36%) decrease in the pain at follow-up compared with the control group (20%). Manniche et al. grouped patients in 50 repetition and 15 repetition groups and a control group for different back extension strengthening exercises46. The study found that the those who underwent rigorous exercise had a decrease in pain symptoms to a large extent. Kankaanpa¨a¨ chose individuals suffering from chronic low back pain to partake in a 12-week functional restoration program40. The program comprised resistive training and a control group who underwent inactive treatments. The study revealed a 54% pain decrease in the active restoration group while no change was noticed in the control group.

However, some studies have not revealed a pain decrease using exercise. For example, Bendix et al. conducted a study consisting of active rehabilitation and community treatments17. The study did not demonstrate any pain decrease in either the treatment or the control group. In addition, Hansen et al. found no pain decrease in a group of patients with low back pain who underwent treatment involving conventional physical therapy and floor exercises48. This indicates that low-intensity exercise might not have much effect on low back pain.

 

Low back pain reduction mechanisms through exercise have not been presently recognized. It has been hypothesized that exercise may result in decreases in low back pain through a physiologic or neurological desensitization procedure of pain-producing tissue or frequent application of pressure or force to the tissue43. Delayed initial muscle pain takes 1-2 days subsequent to exercise. It may also be perceived or understood as low back pain exacerbation by certain patients59. This muscle pain at times increases patients’ worries about further injury. Hence, it must be efficiently approached to avoid destabilization of the exercise program. Regular supports are important in response to successful use of exercise for low back pain treatments.

 


 

Table 2 Changes in low back pain reported by observational studies using exercise for the treatment of chronic low back pain

Study

Subjects

Type of exercise

Changes in low back pain

van der Velde et al. 26

258 patients with chronic low back pain

6-week program of aerobic and flexibility exercises

P > 0.01

Wittink et al.

50

17 patients with chronic low back pain

6-week program of aerobic, stabilizing and endurance exercises

P > 0.01

Taimela et al.

13

125 patients with chronic low back pain

12-week program of strength training and stretching

P < 0.01

Leggett et al.

36

412 patients with chronic low back pain

8-week strength training, endurance training and stretching

P > 0.05

Rainville et

al. 25

77 patients with chronic low back pain

6-week program of strength training, stretching and endurance training

P < 0.01

Hazard et al.

31

59 patients disabled with chronic low back pain

3-week program of strength training, stretching and endurance training with behavioral support

P > 0.05

Mayer et al. 23

74 patients disabled with chronic low back pain

3-week program of strength training, stretching and endurance training with behavioral support

P < 0.05

Holmes et al.

20

18 elderly women with chronic low back pain

14-week program of back strengthening

P < 0.05

Edwards et al. 45

54 patients disabled with chronic low back pain

4 weeks of resistive training, work hardening and manual treatments

P > 0.05

 


VIII. EXERCISE AS TREATMENT FOR BEHAVIORAL, COGNITIVE, AFFECTIVE AND DISABILITY COMPONENTS OF CHRONIC LOW BACK PAIN:

It has been established that behavioral, cognitive and psychosocial factors play fundamental roles in the treatment of chronic low back pain, particularly disability related to low back pain. The techniques through which exercise is used as a helpful modality can be envisioned by recognizing the mechanisms for reducing low back pain.

 

A fear-avoidance model of chronic pain perception was introduced in 1983, referring to two significant potential social responses to the risk of pain; avoidance and confrontation60. Those who are capable of successfully addressing their pain can increase and maintain their social or physical events resulting in a decrease in anxiety and recovery over time. Those who mainly showed reactions of avoidance are more susceptible to increasing chronic symptoms and related physical injury and ill health. Philips61 claimed that avoidance of pain is affected by the expectation that more exposure to particular stimuli can cause distress and pain. Studies that have recently been conducted in this field have concentrated mainly on the anxiety of pain62,63, work-related activities24, movement anticipated to result in or increase injury64,65 and attitudes and beliefs related to pain66,68. All of these studies revealed a significant influence of anxiety, attitudes and beliefs on disability related to low back pain. Therefore, exercise can certainly be utilized to address anxiety, reform attitudes and beliefs, and change social responses to pain.

 

Exercise performed using a quota-based method (pre-established prospects of performance that do not rely upon pain) can act partly as a procedure of desensitizing anxiety. Quota-based, non–pain contingent exercise has been hypothesized by Fordyce et al. as an operant conditioning technique with the purpose of lessening disability or disorderly manners and strengthening attitudes to exercise and health69. They established that an exercise performed using this method results in considerable increases in movement and decreases in pain. Useful rehabilitation programs, which also employ quota-based exercise, have proven decreases in disability and a high level of recurrence to work subsequent to treatment23,31. Other relevant information notes that active restoration has a direct effect on patients’ attitudes and beliefs about pain, and the extent of this effect strongly forecasts disability after treatment28.

 

In the last few decades, several other studies employing exercise as the major technique of treatment suggest that there is a significant decrease in post-treatment disability due to the exercise influence on low back pain13,21,26,40,43,56,70. Studies that have partly demonstrated decreases in low back pain using exercise are summarized in Table 3. Higher incidences of anxiety, substance abuse, depression, somatization and behavioral disorders have been reported more in individuals who have chronic low back pain than the general population. The prevalence of major depression and disorders in the aforementioned patients has been presently estimated to be in the range of 30%-65% 21,71,72,73against 5% to 17% in the general population74. Polatin et al. also determined a high level of anxiety disorders, substance abuse and dependence for people suffering from chronic low back pain. However, whether these disorders occur as a result of suffering from chronic pain and disability or occur before the pain, possibly functioning as causes of the severity, remains under debate71.

 

Gatchel et al. conducted an analysis of emotion in 421 individuals within six weeks of commencement of low back pain75. The study revealed that psychopathology was not the main determinant of severity or persistent disability. A current systematic review of the literature that examines the present proof associating psychological factors with increases in the severity of low back pain revealed that both “distress” (a word used to denote a complex psychological suffering, depressive symptoms, and depressed personality) and somatization were major determinants of negative effects76.

 

Another related systematic review investigated whether work-place psychosocial factors and private life are possible risk factors for the development of low back pain. The review put forward strong proof for low public support in the work-place and low levels of job satisfaction as the major risk factors for low back pain. Meanwhile, there was not enough evidence established for psychosocial factors in private life [77]. Other interesting results from several studies on exercise have recognized enhancements in depression levels subsequent to treatment13,19,31,32,67. These studies found that levels of depression before treatment were insignificant for range moderation. They also found that these enhancements can provide more developments in mood due to enhanced physical abilities and pain than development in the symptoms of major depression.

 

Considering the reasonably high frequency of emotional disorders in people with chronic low back pain, literature related to the influence of exercise on these disorders without low back pain becomes necessary. Most of the current studies investigated the influence of aerobic exercise on depression. The literature generally proposes that depression treatment through exercise is effective and is as effective as antidepressant and psychotherapy treatment. Regrettably, most of the studies had no methodological strengths, and merely three randomized scientific studies on depression treatment through exercise have been published78,80. Only one of these studies used a large enough sample size and adequate follow-up80.

 

It is evident that many studies recognized the existence of exercise benefits as determinants of both decreases in pain and disability45,67,81,84. Nevertheless, the physiological outcomes from exercise are not reasonably influenced by the existence of benefits, thereby making exercise of significant benefit to the people67. Unnecessary anxiety and worries about low back pain cause changes in pain attitudes and beliefs.

 

 

 

 

 

Table 3 Disability outcomes reported by studies employing exercise for the treatment of low back pain

Study

Treatment

Percent change in functional outcomes

Taimela et al. 13

12-week progressive exercise program

P < 0.01

Risch et al. 21

10-week progressive  resistance exercise program

P < 0.05

Mayer et al. 23

3-week functional restoration program

P < 0.05

van der Velde

et al. 26

6-week general conditioning program

P > 0.01

 

Rainville et al.28

7-week functional restoration program

p < 0. 01

Hazard et al. 31

6-week functional restoration program

P > 0.05

Kankaanpa¨a¨ et al. 40

12-week active exercise Program

P < 0.05

Rainville et al.43

6-week active exercise Program

P < 0.01

Frost et al. 56

4-week fitness program

P < 0.05

Mannion et al. 70

12 weeks of stretching and aerobic conditioning, functional restoration or individual Physiotherapy

P < 0.01

 

IX. CONCLUSIONS:

It is evident that exercise can certainly reduce the risk of additional low back pain. The usefulness of exercise in addressing three different features of chronic low back pain condition is recognized. First, exercise can be beneficial in decreasing injuries in functions that are commonly existent in individuals with chronic low back pain. These include decreased back flexibility, strength and cardiovascular endurance. Second, strong evidence suggests that regular exercise may directly decrease low back pain severity. Finally, exercise may be beneficial in reducing disability related to low back pain due to its usage as a tool in minimizing extreme anxiety and worries about low back pain and changing pain attitudes and beliefs.

 

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Received on 19.03.2019           Modified on 21.04.2019

Accepted on 18.05.2019          © RJPT All right reserved

Research J. Pharm. and Tech 2019; 12(9):4313-4323.

DOI: 10.5958/0974-360X.2019.00742.X