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      Supervised and non-supervised Nordic walking in the treatment of chronic low back pain: a single blind randomized clinical trial

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          Abstract

          Background

          Active approaches including both specific and unspecific exercise are probably the most widely recommended treatment for patients with chronic low back pain but it is not known exactly which types of exercise provide the most benefit. Nordic Walking - power walking using ski poles - is a popular and fast growing type of exercise in Northern Europe that has been shown to improve cardiovascular metabolism. Until now, no studies have been performed to investigate whether Nordic Walking has beneficial effects in relation to back pain.

          Methods

          A total of 151 patients with low back and/or leg pain of greater than eight weeks duration were recruited from a hospital based outpatient back pain clinic. Patients continuing to have pain greater than three on the 11-point numeric rating scale after a multidisciplinary intervention were included. Fifteen patients were unable to complete the baseline evaluation and 136 patients were randomized to receive A) Nordic walking supervised by a specially trained instructor twice a week for eight weeks B) One-hour instruction in Nordic walking by a specially trained instructor followed by advice to perform Nordic walking at home as much as they liked for eight weeks or C) Individual oral information consisting of advice to remain active and about maintaining the daily function level that they had achieved during their stay at the backcenter. Primary outcome measures were pain and disability using the Low Back Pain Rating Scale, and functional limitation further assessed using the Patient Specific Function Scale. Furthermore, information on time off work, use of medication, and concurrent treatment for their low back pain was collected. Objective measurements of physical activity levels for the supervised and unsupervised Nordic walking groups were performed using accelerometers. Data were analyzed on an intention-to-treat basis.

          Results

          No mean differences were found between the three groups in relation to any of the outcomes at baseline. For pain, disability, and patient specific function the supervised Nordic walking group generally faired best however no statistically significant differences were found. Regarding the secondary outcome measures, patients in the supervised group tended to use less pain medication, to seek less concurrent care for their back pain, at the eight-week follow-up. There was no difference between physical activity levels for the supervised and unsupervised Nordic walking groups. No negative side effects were reported.

          Conclusion

          We did not find statistically significant differences between eight weeks of supervised or unsupervised Nordic walking and advice to remain active in a group of chronic low back pain patients. Nevertheless, the greatest average improvement tended to favor the supervised Nordic walking group and - taking into account other health related benefits of Nordic walking - this form of exercise may potentially be of benefit to selected groups of chronic back pain patients.

          Trial registration

          http://www.ClinicalTrials.gov # NCT00209820

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          Most cited references 22

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          Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain.

          Exercise therapy encompasses a heterogeneous group of interventions. There continues to be uncertainty about the most effective exercise approach in chronic low back pain. To identify particular exercise intervention characteristics that decrease pain and improve function in adults with nonspecific chronic low back pain. MEDLINE, EMBASE, PsychInfo, CINAHL, and Cochrane Library databases to October 2004 and citation searches and bibliographic reviews of previous systematic reviews. Randomized, controlled trials evaluating exercise therapy in populations with chronic (>12 weeks duration) low back pain. Two reviewers independently extracted data on exercise intervention characteristics: program design (individually designed or standard program), delivery type (independent home exercises, group, or individual supervision), dose or intensity (hours of intervention time), and inclusion of additional conservative interventions. 43 trials of 72 exercise treatment and 31 comparison groups were included. Bayesian multivariable random-effects meta-regression found improved pain scores for individually designed programs (5.4 points [95% credible interval (CrI), 1.3 to 9.5 points]), supervised home exercise (6.1 points [CrI, -0.2 to 12.4 points]), group (4.8 points [CrI, 0.2 to 9.4 points]), and individually supervised programs (5.9 points [CrI, 2.1 to 9.8 points]) compared with home exercises only. High-dose exercise programs fared better than low-dose exercise programs (1.8 points [CrI, -2.1 to 5.5 points]). Interventions that included additional conservative care were better (5.1 points [CrI, 1.8 to 8.4 points]). A model including these most effective intervention characteristics would be expected to demonstrate important improvement in pain (18.1 points [CrI, 11.1 to 25.0 points] compared with no treatment and 13.0 points [CrI, 6.0 to 19.9 points] compared with other conservative treatment) and small improvement in function (5.5 points [CrI, 0.5 to 10.5 points] compared with no treatment and 2.7 points [CrI, -1.7 to 7.1 points] compared with other conservative treatment). Stretching and strengthening demonstrated the largest improvement over comparisons. Limitations of the literature, including low-quality studies with heterogeneous outcome measures and inconsistent and poor reporting; publication bias. Exercise therapy that consists of individually designed programs, including stretching or strengthening, and is delivered with supervision may improve pain and function in chronic nonspecific low back pain. Strategies should be used to encourage adherence. Future studies should test this multivariable model and further assess specific patient-level characteristics and exercise types.
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            Reexamination of validity and reliability of the CSA monitor in walking and running.

            To evaluate the reliability and validity of the CSA (model 7164) accelerometer (MTI) in a wide walking-running speed range in laboratory and field. Twelve male subjects performed three treadmill walking/running sessions and one field trial with the same continuous protocol involving progressively increasing velocities at 5 min per interval from 3 to 6 km x h(-1) (walking) and 8 to 20 km x h(-1) (running). In the field trial, this protocol was terminated after 35 min (14 km.h(-1)), but the trial then extended with 5-km running at a freely chosen velocity. In both scenarios, two CSAs were mounted on each hip and the step frequency measured at each velocity. Oxygen uptake VO(2) x kg(-1) was measured on the last two treadmill sessions. Correlation analyses were performed for mean CSA output relationship with speed, VO(2) per kilogram, and step frequency. In all trials, CSA output rose linearly (R2 = 0.92, P 9 km x h(-1). Estimation errors increased with speed from 11% (P < 0.01) at 10 km x h(-1) to 48% (P < 0.001) at 16 km x h(-1), when assuming a linear relationship. Freely chosen velocities in the field trial ranged from 10.9 to 16.3 km.h-1. No difference in the CSA-speed relationship was observed between the two scenarios. Differences in CSA output between subjects could partially be attributed to differences in step frequency (R = -0.34 (P = 0.02) for walking and R = -0.63 (P < 0.001) for running). CSA output increases linearly with speed in the walking range but not in running, presumably due to relatively constant vertical acceleration in running. Between-subject reliability was related to step frequency because CSA data are filtered most at higher movement frequencies. Epidemiological CSA data should thus be interpreted with these limitations in mind.
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              Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain.

              The purpose of this randomized controlled trial was to examine the usefulness of the addition of specific stabilization exercises to a general back and abdominal muscle exercise approach for patients with subacute or chronic nonspecific back pain by comparing a specific muscle stabilization-enhanced general exercise approach with a general exercise-only approach. Fifty-five patients with recurrent, nonspecific back pain (stabilization-enhanced exercise group: n=29, general exercise-only group: n=26) and no clinical signs suggesting spinal instability were recruited. Both groups received an 8-week exercise intervention and written advice (The Back Book). Outcome was based on self-reported pain (Short-Form McGill Pain Questionnaire), disability (Roland-Morris Disability Questionnaire), and cognitive status (Pain Self-Efficacy Questionnaire, Tampa Scale of Kinesiophobia, Pain Locus of Control Scale) measured immediately before and after intervention and 3 months after the end of the intervention period. Outcome measures for both groups improved. Furthermore, self-reported disability improved more in the general exercise-only group immediately after intervention but not at the 3-month follow-up. There were generally no differences between the 2 exercise approaches for any of the other outcomes. A general exercise program reduced disability in the short term to a greater extent than a stabilization-enhanced exercise approach in patients with recurrent nonspecific low back pain. Stabilization exercises do not appear to provide additional benefit to patients with subacute or chronic low back pain who have no clinical signs suggesting the presence of spinal instability.
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                Author and article information

                Journal
                BMC Musculoskelet Disord
                BMC Musculoskeletal Disorders
                BioMed Central
                1471-2474
                2010
                10 February 2010
                : 11
                : 30
                Affiliations
                [1 ]Clinical Locomotion Science, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, DK-5230 odense M, Denmark
                [2 ]Nordic Institute of Chiropractic and Clinical Biomechanics, part of Clinical Locomotion Science, Forskerparken 10A, DK-5230 Odense M, Denmark
                [3 ]The Back Research Center, part of Clinical Locomotion Science, University of Southern Denmark, Lindevej 5, DK-5750 Ringe, Denmark
                Article
                1471-2474-11-30
                10.1186/1471-2474-11-30
                2831827
                20146793
                Copyright ©2010 Hartvigsen et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Research article

                Orthopedics

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