Low back pain: unfit? just not doing much? or something else


ResearchBlogging.org
For as long as I’ve been working in pain management (and probably well before), I’ve heard patients being described as ‘deconditioned’. From what we know about the effects of staying in bed because of illness or injury, it makes sense to think that if a person does very little they will become unfit. Common sense really. And from this assumption an industry of gym programmes and fitness initiatives have been instituted as an integral part of back pain rehabilitation.

Now before my physiotherapy colleagues start to lynch me, I’m not saying that these programmes should be banished into outer darkness because ‘reactivation’ has been shown to be effective in the recovery from back pain – but maybe it’s effective for quite a different reason from the one usually given.

Verbunt, Smeets & Wittink, in this editorial from Pain conduct a review of the relationship between physical inactivity and deconditioning in people with non-specific chronic low back pain, and find scant evidence for the strength of this belief.  Ooops.

There are several theoretical models that integrate the hypothesis that deconditioning is part of, and complicates, the recovery of people with chronic low back pain. The most popular in recent years is the pain-related anxiety and avoidance model (Vlaeyen and colleagues), in which people misinterpret their pain as threatening or something to be avoided at all cost, consequently fear moving, stop doing normal activities of daily living, and become deconditioned.  The model has been incredibly helpful for initiating a graded exposure approach to feared movements, and for shifting the psychological focus from low mood and into anxiety about pain and consequent behaviours.  BUT, as this review points out, it’s unclear whether being inactive and deconditioned maintain the ongoing disability.  And there is little evidence that being fit protects against experiencing low back pain in the first place.

As I said before, I’m definitely not arguing against the use of exercise as a component of rehabilitation for chronic low back pain – but at the same time, it’s really important to make sure the rationale for this is based on reality, not a myth.

Back to the findings of this review.  Firstly, is there evidence that people with chronic low back pain are actually doing less than people without? Basically, no.  But the pattern of activity can be quite different – people with ongoing tend to be just as active overall in a day, but their activity has peaks and troughs, what can be called ‘boom and bust’, or ‘saw-tooth’ pattern of activity.   Studies also show that people’s disability level is associated with their perception of how little they did – and this didn’t relate to their actual activity level.  Now that’s interesting – feeling like activities are obstructed by pain seems more salient to disability than the actual amount of activity carried out.  Perception is reality.

Are people with chronic low back pain less fit?

Several parameters are explored in this paper – deconditioning should be linked to changes in body composition (fat vs muscle), bone strength, muscle control and cardiovascular changes.

  • Body fat percentages are higher in people with chronic low back pain – but bone strength is equivocal.

Muscle strength and endurance should be affected if a person is deconditioned: ‘adaptive remodelling in muscles’.   This should be reflected in atrophic changes to the muscle as well as changes to the type of fibre found in muscles.

  • While some studies seem to show changes in paraspinal muscles, generalised atrophy isn’t found.  Biopsy of muscle fibres show atrophy of type II fibres, and this appears to be related to the duration of the low back pain. But the authors in this paper point out that these changes could be atrophy due to aging rather than back pain, and there were no studies to show the ratio between type I and IIX fibres in people with or without low back pain.
  • Postural control studies haven’t controlled for the level of physical activities of daily living, so it’s unclear whether any differences found are due to overall low activity level (which could have existed prior to the onset of back pain), or whether any changes were as a result of doing less because of low back pain.
  • Cardio fitness – well, here’s a kettle of fish.  There are loads of confounds – the type of exercise protocol used, work status comparisons, diagnostic comparisons, age and gender matching – it’s just not pretty.  This paper points out that there is conflicting evidence regarding cardiovascular deconditioning, or whether those who are working despite chronic low back pain are ‘fitter’ than those who are not, although there does appear to be a gender difference – males who are working appear to have better aerobic fitness than either women who worked outside the home, or males who did not work outside the home.  Maybe returning to work prevents cardiovascular deconditioning – but it’s unclear whether the types of work between women and men (both work in the home, and outside of the home) were controlled for.  Almost all the studies have used a cross-sectional design, so it’s really difficult to know whether deconditioning occurs after onset of pain, or prior to the onset of pain.  Low aerobic fitness and low activity levels do not appear to be risk factors for developing chronic low back pain.
  • Metabolic factors – insulin insensitivity is associated with low activity levels like lots of bed rest.  Unfortunately there were not studies examining this in people with chronic low back pain, and the level of inactivity required to develop insulin insensitivity hasn’t been determined.

Now it really does get interesting for me here.  I’ve griped about the lack of validity (and reliability) of functional capacity evaluations.  They rely on people being prepared to ‘give it their best’ and for many reasons people with chronic pain may not do so.  It could their concerns about pain immediately, pain the next day, or the implications of ‘good’ performance on things like compensation.  On the other hand, a one-shot assessment isn’t able to predict performance over a day or a week – and some patients ‘over-do’, others ‘under-do’, and even the influence of the person doing the assessment can change how well the individual performs a functional test.

The authors in this paper plead for researchers to:

(1) objectively monitor general physical activity level and control for this in statistical analyses of physical fitness

(2) consider studying the factors that influence performance during performance testing in order to improve validity

(3) use longitudinal designs rather than cross-section designs to ensure correlation isn’t confused with causation – and outcome measures should monitor the impact of functional activity gains

(4) confounds known to influence physical performance usch as gender, age, recreational activities, job type, diagnosis, etc should be monitored so multiple regressions can be carried out with some confidence

The summary?

There is little research evidence that people with chronic low back pain are deconditioned either before they developed their problem, or after.  Despite this, it’s thought that being fit in a generally active way is good for overall health and especially as we age.  Engaging in more exericse does have an effect on recovery from low back pain (well, reducing the disability associated with low back pain), but we don’t know why.  Just don’t assume that because someone perceives they’re disabled, they are actually unfit.

Verbunt JA, Smeets RJ, & Wittink HM (2010). Cause or effect? Deconditioning and chronic low back pain. Pain PMID: 20153582

10 comments

  1. Nice. And moves on to ask the question – If you find that someone is unfit / deconditioned, and in pain, does making them fitter help?

    Presumably a lot of the benefit of physiotherapy-led exercise is the reassurance implied that it is appropriate to move, and the relevance of the activity to the individual (ie not going hell for leather just because they have been given ‘the green light’).

    What if the person was already in poor physical condition before their pain (obesity levels are high in the general population in many western countries)? if job satisfaction, prolonged lowered mood and self-efficacy are the big indicators for susceptibility to chronic pain (which could be the case) does that mean all the fitties out there love their jobs, love their lives and have super confidence? Not in my workplace!

    Chronic low back pain and more exercise was always too simple an equation. But physiotherapists, who are often the clinician facing this type of patient (until ACC started charging), have good exercise knowledge, can recognise a yellow flag when it’s waved in their face and have the respect of their patients (we aren’t going to tell them they are going mad). We have more time than a GP to listen, usually have a focus on function and often encourage self-management (even if it is just a simple home stretching programme), rather than passive interventions.

    So it works – we just haven’t identified which part of it is so effective!

    Thanks for another thought provoking blog – your drive and passion is inspiring (and a little scary)

    P

  2. There is a lot of confusing information available about back pain. I like to keep things simple by using a quick little test. Try this out. It’ll literally take 1 minute.
    Lie down on your back for 30 seconds with legs extended out, resting on the floor. Now bend your knees so the feet are sitting flat on the floor near your behind for 30 seconds. Which one feels better? If your back pain diminishes with knees bent then your spine has excessive extension stress acting on it. There are simple exercises to correct this. If your spine felt better with legs extended then you have excessive flexion stress acting on your spine. Again this is easily correctable.
    Chronic pain results from a cycle of issues. Anatomical problems feed biomechanical issues which then affect movement habits that reinforce the original anatomical and biomechanical problems. Fixing back pain requires attention to all three levels. It’s quite simple to correct though and outlined this in my book. I’m very successful treating chronic pain and it is likely this information will be the key you’ve been missing to fix your pain. I’ve also posted this test on YouTube, if you’re interested.

    1. Dear Rick
      With the greatest of respect, I have to disagree with you in terms of your analysis of both the ‘problem’ of low back pain and your solution. The literature is replete with studies demonstrating that the approach you recommend doesn’t always provide outcomes that are durable, or even relate to the disability that people experience, and this is in part to the underlying assumptions you’re drawing on to base your treatment. I don’t doubt that for some people, in some circumstances, at some times, what you’ve suggested is helpful – but it’s simplistic, doesn’t recognise that pain is about how the brain is making sense of information coming from tissues, and involves biophysical, psychological and social factors. Can I encourage you to take some time to read the journal articles in publications like Pain, Clinical Journal of Pain, Spine and so on, to expand your views?
      Thanks for taking the time to comment.
      regards
      Bronnie

      1. Thanks Bronnie,
        But as a clinician who specializes in treating chronic pain, with almost a 100% success rate for low back pain treatment over the last 5 years, I stand by my treatment approach. Of course there are psychosocial issues involved which I take into account with my treatment. These issues fall on a continuum with mechanical issues, where in most cases, mechanics are responsible for the majority of the pain. I perfectly understand there are those who would disagree, however my results speak for themselves.
        I agree my post represents a simplistic view but it is not my purpose to write a treatise on back pain treatment, merely expose your readers to a different way of thinking that provides predictable and consistent results also backed by volumes of research.
        Thanks for your comments.
        Regards
        Rick
        Thanks for your

  3. Quote from Rick Olderman:

    But as a clinician who specializes in treating chronic pain, with almost a 100% success rate for low back pain treatment over the last 5 years, I stand by my treatment approach.

    WHAT?? almost 100%?
    Definitely, I’m sorry, but I can’t believe that.

    @Bronnie: I agree with you. Pain, Clinical Journal of Pain, Spine would be a nice start.

    C.

    1. Dear Rick
      I think if you are achieving an almost 100% success rate you need to write your methodology up for a peer-reviewed journal and let other clinicians know the characteristics of who you’re seeing, your treatment approach and your outcome measures. Peer review is really the only way to make the sort of claims you’re making in a way that academics and clinicians will accept.
      Thanks
      Bronnie

  4. I have found great help from a physiotherapist who emphasized on flexibility and going back to the natural movements and standing position and to unstress every movement you make which if done consequently helps for every kind of back pain

    1. Hi Jan
      Thanks for telling us about your experience with back pain and physiotherapy. I agree that moving normally and naturally really helps with back pain, and for some people it’s necessary to see a therapist to help with this process. The research doesn’t seem to indicate any specific type of physiotherapy or exercise, it just emphasises the need to move, which I think probably provides ‘normal’ input to the neuromatrix, helping to return the brain to equilibrium, but that’s a hypothesis that is still being studied. It’s also especially good to see that you found that learning about movement can then be applied every time pain flares up – it’s that part of self management that can sometimes be forgotten! Thanks for taking the time to comment!
      cheers
      Bronnie

  5. I see the problems caused by the “Sawtooth” activity pattern in many of my clients. It makes perfect sense that many people would have this issue, as most of us are only physically active for a portion of the day. Many people with labor intensive jobs suffer from low back pain after the cooling off period, when the musculature has begun to stiffen instead of relax and recover. I regularly recommend a set of streches and excercises to my Chiropractic patients which are reported to be quite effective in pre-empting incapacitating pain and rigidity.

    Great piece. Thanks for getting the info out!

    1. It makes sense in the short term to engage in the boom and bust pattern – but for people with chronic pain, it leads to a whole lot of disability. Irrespective of the mechanisms (central or peripheral), in the end the best strategy is to carry out time contingent activity and maintain ‘no more on a good day, no less on a bad day’.

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