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      Facilitators and barriers to physical activity in people with chronic low back pain: A qualitative study

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          Abstract

          Background

          For medical teams, one of the main objectives of rehabilitation for people with chronic low back pain is adherence to physical activity (PA).

          Objective

          The objective of this study was to identify PA barriers and facilitators in this population.

          Methods

          This qualitative study included 4 discussion groups and 16 semi-structured interviews conducted among people with non-specific chronic low back pain who were involved in a specific rehabilitation program or seen in primary care settings.

          Results

          Three main themes were identified: physical factors, psychological factors and socio-environmental factors. The main barrier to PA practice is pain. Psychological barriers were associated with the difficulty in integrating PA in the person’s daily life. Environmental barriers were dominated by lack of time. Facilitators identified associated the supervised nature of the physical activity (supervision by professionals) and group practice, which improved people’s adherence.

          Conclusion

          The results of this study will allow teams to target relevant educational objectives for these people and develop dedicated self-management programs.

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          Most cited references33

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          Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.

          Roger Chou, Laurie Huffman (2007)
          Many nonpharmacologic therapies are available for treatment of low back pain. To assess benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain). English-language studies were identified through searches of MEDLINE (through November 2006) and the Cochrane Database of Systematic Reviews (2006, Issue 4). These electronic searches were supplemented by hand searching of reference lists and additional citations suggested by experts. Systematic reviews and randomized trials of 1 or more of the preceding therapies for acute or chronic low back pain (with or without leg pain) that reported pain outcomes, back-specific function, general health status, work disability, or patient satisfaction. We abstracted information about study design, population characteristics, interventions, outcomes, and adverse events. To grade methodological quality, we used the Oxman criteria for systematic reviews and the Cochrane Back Review Group criteria for individual trials. We found good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (>4 weeks' duration) low back pain. Benefits over placebo, sham therapy, or no treatment averaged 10 to 20 points on a 100-point visual analogue pain scale, 2 to 4 points on the Roland-Morris Disability Questionnaire, or a standardized mean difference of 0.5 to 0.8. We found fair evidence that acupuncture, massage, yoga (Viniyoga), and functional restoration are also effective for chronic low back pain. For acute low back pain (<4 weeks' duration), the only nonpharmacologic therapies with evidence of efficacy are superficial heat (good evidence for moderate benefits) and spinal manipulation (fair evidence for small to moderate benefits). Although serious harms seemed to be rare, data on harms were poorly reported. No trials addressed optimal sequencing of therapies, and methods for tailoring therapy to individual patients are still in early stages of development. Evidence is insufficient to evaluate the efficacy of therapies for sciatica. Our primary source of data was systematic reviews. We included non-English-language trials only if they were included in English-language systematic reviews. Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation. For acute low back pain, the only therapy with good evidence of efficacy is superficial heat.
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            1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain.

            GORDON WADDELL (1987)
            Because there is increasing concern about low-back disability and its current medical management, this analysis attempts to construct a new theoretic framework for treatment. Observations of natural history and epidemiology suggest that low-back pain should be a benign, self-limiting condition, that low back-disability as opposed to pain is a relatively recent Western epidemic, and that the role of medicine in that epidemic must be critically examined. The traditional medical model of disease is contrasted with a biopsychosocial model of illness to analyze success and failure in low-back disorders. Studies of the mathematical relationship between the elements of illness in chronic low-back pain suggest that the biopsychosocial concept can be used as an operational model that explains many clinical observations. This model is used to compare rest and active rehabilitation for low-back pain. Rest is the commonest treatment prescribed after analgesics but is based on a doubtful rationale, and there is little evidence of any lasting benefit. There is, however, little doubt about the harmful effects--especially of prolonged bed rest. Conversely, there is no evidence that activity is harmful and, contrary to common belief, it does not necessarily make the pain worse. Experimental studies clearly show that controlled exercises not only restore function, reduce distress and illness behavior, and promote return to work, but actually reduce pain. Clinical studies confirm the value of active rehabilitation in practice. To achieve the goal of treating patients rather than spines, we must approach low-back disability as an illness rather than low-back pain as a purely physical disease. We must distinguish pain as a purely the symptoms and signs of distress and illness behavior from those of physical disease, and nominal from substantive diagnoses. Management must change from a negative philosophy of rest for pain to more active restoration of function. Only a new model and understanding of illness by physicians and patients alike makes real change possible.
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              Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain.

              Jill Hayden, Maurits W van Tulder, George Tomlinson (2005)
              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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                Author and article information

                Contributors
                Ruth Jepson: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 25 July 2017
                Publication date Collection: 2017
                Volume: 12
                Issue: 7
                Electronic Location Identifier: e0179826
                Affiliations
                [1 ] Service de Médecine Physique et de Réadaptation, Centre Hospitalier Universitaire, Clermont-Ferrand, France
                [2 ] INRA, Université Clermont Auvergne, Clermont-Ferrand, France
                [3 ] Service de Médecine Physique et de Réadaptation, Faculté de Médecine Montpellier-Nîmes, Centre Hospitalier Universitaire Carémeau, Nîmes, France
                [4 ] Euromov, Université de Montpellier, Montpellier, France
                University of Edinburgh, UNITED KINGDOM
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: EC AD.

                • Data curation: LB CR.

                • Formal analysis: EC ER LB CR.

                • Investigation: ER.

                • Methodology: AD EC.

                • Project administration: EC.

                • Resources: EC.

                • Supervision: EC.

                • Validation: EC.

                • Visualization: AD EC.

                • Writing – original draft: LB EC.

                • Writing – review & editing: AD.

                Author information
                http://orcid.org/0000-0001-5085-3739
                Article
                Publisher ID: PONE-D-16-43473
                DOI: 10.1371/journal.pone.0179826
                PMC ID: 5526504
                PubMed ID: 28742820
                SO-VID: ae930238-4613-40ce-9115-f29fc258ba56
                Copyright © © 2017 Boutevillain et al
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 1 November 2016
                Date accepted : 5 June 2017
                Page count
                Figures: 1, Tables: 2, Pages: 16
                Funding
                The authors received no specific funding for this work.
                Categories
                Subject: Research Article
                Subject: Medicine and Health Sciences
                Subject: Diagnostic Medicine
                Subject: Signs and Symptoms
                Subject: Pain
                Subject: Lower Back Pain
                Subject: Medicine and Health Sciences
                Subject: Pathology and Laboratory Medicine
                Subject: Signs and Symptoms
                Subject: Pain
                Subject: Lower Back Pain
                Subject: Medicine and Health Sciences
                Subject: Public and Occupational Health
                Subject: Physical Activity
                Subject: Medicine and Health Sciences
                Subject: Public and Occupational Health
                Subject: Physical Activity
                Subject: Physical Fitness
                Subject: Exercise
                Subject: Medicine and Health Sciences
                Subject: Sports and Exercise Medicine
                Subject: Exercise
                Subject: Biology and Life Sciences
                Subject: Sports Science
                Subject: Sports and Exercise Medicine
                Subject: Exercise
                Subject: Research and Analysis Methods
                Subject: Research Design
                Subject: Qualitative Studies
                Subject: Biology and Life Sciences
                Subject: Physiology
                Subject: Biological Locomotion
                Subject: Walking
                Subject: Medicine and Health Sciences
                Subject: Physiology
                Subject: Biological Locomotion
                Subject: Walking
                Subject: Biology and Life Sciences
                Subject: Psychology
                Subject: Emotions
                Subject: Fear
                Subject: Social Sciences
                Subject: Psychology
                Subject: Emotions
                Subject: Fear
                Subject: Medicine and Health Sciences
                Subject: Pain Management
                Subject: Pain Psychology
                Subject: Biology and Life Sciences
                Subject: Psychology
                Subject: Pain Psychology
                Subject: Social Sciences
                Subject: Psychology
                Subject: Pain Psychology
                Subject: Social Sciences
                Subject: Sociology
                Subject: Human Families
                Custom metadata
                Data Availability All relevant data are within the paper and its Supporting Information files.

                ScienceOpen disciplines: Uncategorized
                Data availability:
                ScienceOpen disciplines: Uncategorized

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