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LB exercise vs. general physical activity

 
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LB exercise vs. general physical activity - November 28, 2005 11:47:00 AM   
apolipo

 

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Curious about others opinions regarding the article below:

[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16186460&query_hl=2]Recreational activity vs. exercise for LBP[/URL]

The basic premise is such: being physically active has a positive influence on LBP while specific back exercises are likely to have a negative impact on LBP.

The authors back up their findings with the following systematic review:

[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11064524&query_hl=6]specific exercise and LBP[/URL]

The main problems with the first study was that they used pt. self-report regarding how much "general physical activity" was done, how much "specific exercise" was done, and what constitutes each.

If the results of both studies are accurate and hold up to further study, looks kind of bad for much of our profession, doesn't it?

mike t
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Re: LB exercise vs. general physical activity - November 28, 2005 2:36:00 PM   
nari

 

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The lack of specification with regards to what was done by both groups is something of a flaw in the article; there is the issue of noncompliance to begin with.
If the results are an accurate representation of what 'works' and what doesn't, it is no surprise.
I think our track record for specific exercise is fairly dismal, given the follwoing surmises:
If a LBP person attended PT 2x week for six weeks and improves - how do we assign credit to what we did? That person might have become better anyway.
If he/she had attended once or twice and was painless after that, we might be able to credit ourselves, but evidence is still shaky.
There are many studies around, some not so accurate, suggesting that only 15% of LBP fail to improve with or without PT, and they go on to chronic disability. The McGuirk study is interesting reading...I haven't a reference to it but it is available through google.
Education on pain seems to be the reliable way to go; with that, LBP patients can probably do their own thing just as well as 'going to the PT'.

Nari

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Re: LB exercise vs. general physical activity - November 28, 2005 8:04:00 PM   
Jon Newman

 

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I don't think it looks bad for the future of PT necessarily although it might change the advice we give people. I suppose it might put an end to some of the nonsense that currently occurs in PT but I can't see that as a bad thing for the profession.

jon

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Re: LB exercise vs. general physical activity - November 28, 2005 9:06:00 PM   
nari

 

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jon, I was trying to say something about 'some of the nonsense that currently occurs in PT', but I'm glad you said it more directly!!
Definitely not a bad thing for the profession; perhaps more attention can be paid to other aspects, as we are stretched pretty thinly across all the fields we work in.

Nari

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Re: LB exercise vs. general physical activity - November 29, 2005 9:24:00 AM   
apolipo

 

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One of my first reactions from reading the first article was "Don't let insurance companies see this!". Even though the methodology has some major flaws, which Nari pointed out, research like this could fuel any group wishing to make PT look bad or third party payers wishing to save a dime.

Stuff like this should be a 2x4 to the side of our collective head. I know I am preaching to the choir here but we need to move away from being technique-based technicians who try all the tools in the toolbox one by one until they have nothing left and throw up their hands in frustration.

I think Nari is correct in that PTs need to be better at educating pts. as to what pain is, where it originates, and what the pt. can do about it.

mike t

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Re: LB exercise vs. general physical activity - November 29, 2005 6:09:00 PM   
Bill Egan

 

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There are too many uncontrolled variables in this secondary regression analysis for it to really give us any useful information about how to treat our patients with low back pain.

I am not a big proponent of the McKenzie method, but check out this study by Long et al. They found more favorable outcomes when patients did specific back exercise that matched their directional preference (Flexion, extension, or lateral/rotation). Note that 26% of the subjects did not display a directional preference and were therefore excluded from the study. Perhaps these patients would respond best to more generalized physical activity.

Bill

Spine. 2004 Dec 1;29(23):2593-602.

Does it matter which exercise? A randomized control trial of exercise for low
back pain.

Long A, Donelson R, Fung T.

Bonavista Physical Therapy, Calgary, Alberta, Canada. longma@telusplanet.net

STUDY DESIGN: Multicentered randomized controlled trial. OBJECTIVES: To
determine if previously validated low back pain (LBP) subgroups respond
differently to contrasting exercise prescriptions. SUMMARY OF BACKGROUND DATA:
The role of "patient-specific" exercises in managing LBP is controversial.
METHODS: A total of 312 acute, subacute, and chronic patients, including
LBP-only and sciatica, underwent a standardized mechanical assessment
classifying them by their pain response, specifically eliciting either a
"directional preference" (DP) (i.e., an immediate, lasting improvement in pain
from performing either repeated lumbar flexion, extension, or sideglide/rotation
tests), or no DP. Only DP subjects were randomized to: 1) directional exercises
"matching" their preferred direction (DP), 2) exercises directionally "opposite"
their DP, or 3) "nondirectional" exercises. Outcome measures included pain
intensity, location, disability, medication use, degree of recovery, depression,
and work interference. RESULTS: A DP was elicited in 74% (230) of subjects. One
third of both the opposite and non-directionally treated subjects withdrew
within 2 weeks because of no improvement or worsening (no matched subject
withdrew). Significantly greater improvements occurred in matched subjects
compared with both other treatment groups in every outcome (P values <0.001),
including a threefold decrease in medication use. CONCLUSIONS: Consistent with
prior evidence, a standardized mechanical assessment identified a large subgroup
of LBP patients with a DP. Regardless of subjects' direction of preference, the
response to contrasting exercise prescriptions was significantly different:
exercises matching subjects' DP significantly and rapidly decreased pain and
medication use and improved in all other outcomes. If repeatable, such subgroup
validation has important implications for LBP management.

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Re: LB exercise vs. general physical activity - November 29, 2005 7:20:00 PM   
JLS_PT_OCS

 

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Well said, Bill.

I am shocked as I read the first citation Mike made. The conclusions drawn by the researchers are so obviously flawed, in a "correlation is not causation" kind of way, that I can't even begin to illustrate how many logical fallacies are being demonstrated. So much for peer review, who's doing that at the American Journal of Public Health?

Once again, we see the classic flaw of treating all LBP as a homogenous group, and completely ignoring the issue of subgrouping that Bill alludes to above.

I have an excellent article to publish in the next American Journal of Public Health. I'm going to take two groups of diabetic patients, one group on medication for their disease and one group not on medication for diabetes. I'm going to compare their incidence of secondary sequelae in 10 years. Retinopathy, peripheral neuropathy, etc. When the group on medication (ie the group unable to get good blood sugar control with diet and exercise only) shows a higher incidence of problems, I'm going to go ahead and recommend that diabetic patients not take their medicine, because it's associated with a poor outcome.

I believe also, that being on chemotherapy is a poor prognostic factor for cancer patients, as cancer patients not on chemotherapy (ie those in remission) have a better prognosis.

Can everyone not see the idiocy of these conclusions? If this is the state of logical reasoning and critical thinking at this supposedly peer reviewed journal, then I'm going to recommend we all use it for toilet paper.
EBP indeed. Hah.
J

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Re: LB exercise vs. general physical activity - November 29, 2005 8:00:00 PM   
Jon Newman

 

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Perhaps this paper is worth dissecting fully. It is an RCT that considered both longitudinal and cross sectional data, generically making it strong study design. It would be interesting to see what data it produced that's worth holding onto (based on logic/reason) and what is not so informative. I think that is truly the essence of EBP.

jon

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Re: LB exercise vs. general physical activity - November 29, 2005 8:03:00 PM   
JLS_PT_OCS

 

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I would agree. If the abstract is the best they've got, then I wonder if there is much of anything that can be judged a cause/effect relationship vs just a correlation effect.
J

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Re: LB exercise vs. general physical activity - November 29, 2005 9:37:00 PM   
Jon Newman

 

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Here's a bit from the full text, addressing limitations and strengths.

[QUOTE] Several limitations of this study should be
considered when interpreting our findings.
Our participants were primary care patients
taking part in an investigation of treatment
options for low back pain. Thus, they may
not be representative of individuals with low
back pain who present for care in other kinds
of clinical settings (e.g., specialty clinics or
centers focusing on third party liability or
workers' compensation cases) or who do not
seek clinical treatment at all. Because all of the participants had low back pain at baseline,
we cannot draw inferences about the associations
of exercise and physical activity
with pain or disability and psychological distress in initially pain-free populations. Also,
because the outcomes assessed here are relatively
common, the odds ratios observed
probably tended to overestimate reductions in
relative risks. Furthermore, information on
specific types of back exercises was not collected.
Although little evidence indicating that
some specific exercise regimens are more effective
than others exists in the literature, certain
exercise regimens may be more effective
than others. Also, we relied on participants'
self-reports of their exercise and physical activities,
and it was not feasible to validate responses
with other strategies such as direct
observation.

Because recreational physical activity was
not randomized, confounding is an additional
concern, although we considered the most important
potential confounders in our analytic
strategy. Residual confounding is possible,
however. For example, individuals with more
chronic or disabling histories of back pain
may be more likely than those with less severe
or chronic histories to engage in regular
back exercise. Although we controlled statistically
for baseline duration of low back pain
episode and number of previous episodes of
pain, our back exercise estimates could still
be subject to residual confounding. However,
it is unlikely that such confounding would be
so substantial as to mask truly protective back
exercise effects.

Although these limitations weaken our ability
to offer firm causal inferences, our study
involved a number of strengths that support
the possibility that the associations observed
may in fact be causal. First, the 18-month follow-
up rate of almost 90% diminishes the
possibility that our findings were due entirely
to selection bias. Second, we controlled for
several factors likely to confound crude associations
of exercise and physical activity with
subsequent pain, disability, and psychological
distress. Third, previously validated measures
were used in assessing all outcomes, and well established
MET values were assigned to
physical activity categories. Finally, because
our serial assessments involved a large population
of low back pain sufferers, we were
able to conduct analyses that clearly delineated
the temporal relations of exposures and
outcomes. The stronger cross-sectional than
longitudinal associations observed suggest
possible reverse causation, a problem inherent
in interpreting estimates derived from
cross-sectional studies of physicai activity and
low back pain.

In summary, in a population of primary
care patients presenting with low back pain,
participation in recreational physical activities
was inversely associated, both cross-sectionally
and longitudinally, with low
back pain, related disability, and psychological
distress. In contrast, back exercise was
positively associated both cross-sectionally
and longitudinally with low back pain and
related disability. These results suggest that
individuals with low back pain, rather than
being advised to engage in specific back exercises,
should instead be encouraged to
focus on nonspecific physical activities to
help reduce their pain and improve their
psychological health. Because of the perception
that physical activity could result in
pain persisting for a longer period and fear
of pain have been identified as possible factors
keeping low back pain patients from
being physically active, clinicians may
want to reduce such barriers to patients
modifying their behavior [/QUOTE]jon

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Re: LB exercise vs. general physical activity - November 29, 2005 11:13:00 PM   
nari

 

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Ahh..that's clarifies the meaning of the conclusions better.
Always rather dodgy drawing any accurate conclusions from abstracts.

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Re: LB exercise vs. general physical activity - November 30, 2005 7:43:00 AM   
JLS_PT_OCS

 

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Also, it's dodgier to make a strong statement in your abstract that your full text essentially retracts.
As Bill said, I'm not sure this helps us treat our patients with low back pain any better.
Advice to keep as active as possible is probably given by every PT in the world, and it's part of several CPGs.
Seems a lot of work to give everyone essentially no new information.
J

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jasonsilvernail@gmail.com

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Re: LB exercise vs. general physical activity - November 30, 2005 8:42:00 AM   
FLAOrthoPT

 

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great EBM sites:
[URL=http://www.ptjournal.org]www.ptjournal.org[/URL] october 2001 issue for the philadelphia panel

PEDro (look it up in google)

Hooked on evidence (.com to go to the site)

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Re: LB exercise vs. general physical activity - November 30, 2005 10:01:00 AM   
Jon Newman

 

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Jason, I think you described much of what is available as evidence. It seems that many studies are not unlike diagnostic imaging. It is used to confirm something we already suspect versus to tell us something new.

jon

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Re: LB exercise vs. general physical activity - November 30, 2005 10:57:00 AM   
JLS_PT_OCS

 

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Yes, I agree, Jon.
However, there are some notable exceptions in terms of outcomes research for different treatment approaches, classification issues, etc which are therefore much more interesting.

I think confirming a suspicion or clinical knowledge through research is important. However, we should ask ourselves how many times and in how many ways that needs to be done. I believe the central question this paper addresses (do people who rejoin their daily activities do better than those whose main activity is their rehab exercise) has been answered many times and therefore does not seem to inform the debate about how these patients should be treated.
J

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www.silvernailstudios.com
jasonsilvernail@gmail.com

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Re: LB exercise vs. general physical activity - November 30, 2005 12:46:00 PM   
Jon Newman

 

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Since people were randomized to one of four treatment groups (Chiropractic with or without modalities, "medical care" with or without PT). If you're right that we (PT's) are all are giving the type of advice recommended by this study then those in the PT group would have gotten said advice as well as the possibility of being "classified" and being given tailored exercises. Yet the PT group did not do better. I think understanding what may have happened is worth exploring. Of course it is speculation but some possiblities are the PT's in this study

1. didn't give this type of advice (or if they did, the advice is not
actually the critical component)
2. provided iatrogenic treatment
3. had an unlucky draw that would be solved by
a repetition of the study.
4. didn't adhere to evidence to guide their
practice

Any other ideas what may have happened.

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Re: LB exercise vs. general physical activity - November 30, 2005 8:05:00 PM   
nari

 

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I think this study is too broadly based, comparing one therapy with another (chiro and PT) and all the different intradisciplinary variables.
Even if the treatment criteria were listed as a,b,c and d: there is not much consistency amongst PTs, as is evident from this board and others!

I think one has to compare apples with apples, and one variety of apple with another.

nari

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Re: LB exercise vs. general physical activity - November 30, 2005 8:59:00 PM   
Jon Newman

 

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Hi Nari,

Public health studies tend to, by their nature, look at general populations versus specifics. Jason is quite right that this study won't tell us what to do. Yet I think there is something to learn here anyway. It is plausible that focusing on specific exercises for the back carries with it the "knowledge" that something is specifically wrong AND detectable about a person's back, usually structurally. The "medical care" only folks have the opportunity to escape this situation by giving good (by most accounts) advice to stay active and to reassure them that they are structurally ok. In some ways it is unfortunate that many PT's feel compelled to assume the burden of labeling patients structurally unsound as it might be that this very process could be unhelpful in the overall picture. A couple of solutions currently being used by some are
1. Explain pain (based on grounded pain physiology) to patients in a way that makes sense and doesn't dwell on undetectable (or unreliably detectable) orthopedic structural problems that may or may not have anything to do with why they actually have pain. Of course, you already knew this.

2. outcome studies that establish criteria for treatment without actually making an effort to label a structural problem that needs to be fixed.

Of course when we can implicate, with certainty, a specific structure or pathology (and we can fix it with PT), that should be done but this is often not the case in low back pain.

jon

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Re: LB exercise vs. general physical activity - November 30, 2005 11:51:00 PM   
avalon

 

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Hi all,

I think that focused exercises will ever fail against recreational ones.

1/ they distract attention from the "painful" site more easily.
2/ they are less boring.
3/ less artificial.
4/ they decrease the "importance" of the problem.
5/ they are more "integrated" by the whole body.

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Re: LB exercise vs. general physical activity - December 1, 2005 2:44:00 AM   
nari

 

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Hello jon,

As usual, you hit nails on the head.
Part of our downfall IS trying to label "back pain" as having a 'cause' that requires a label, be it disc, joint,ligament, muscle or whatever happens to be in the firing line. It is unusual to be able to accurately identify a structure as a 'cause' for pain with regard to LBP. Total central prolapse is one of them, perhaps.
I agree that the study does not tell us 'how' to treat; I am more interested in the 'why' we should treat them apart from pain physiology ed. and attention to the origin of the pain. But this has been reiterated so many times, as you know, that it does become frustrating at times... :mad:

No, I'm not really angry....

Henry,

A rather unpopular neurosurgeon I came to know very well over 11 years in his ward, did not like PT intervention with his post-surgical spinal pts.
He would say that PTs can do more harm than good.
At the time it was frustrating, and I negotiated to see these people anyway - but I did not win any brownie points.
He advocated walking, cycling (?)and swimming only; and when one thinks about it, they are functional movements, except for the cycling, but it might be argued that it is a feasible activity. Not that a surgeon would actually know very much about such things.....

Integration is important, particularly in the light of pain physiology.
Your 4 points make sense, along with education.

Nari

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