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Long-term exercise adherence after intensive rehabilitation for chronic low back pain


Medicine & Science in Sports & Exercise: March 2000 - Volume 32 - Issue 3 - pp 551-557
CLINICAL SCIENCES: Clinical Investigation

HARTIGAN, C., J. RAINVILLE, J. B. SOBEL, and M. HIPONA. Long-term exercise adherence after intensive rehabilitation for chronic low back pain. Med. Sci. Sports Exerc., Vol. 32, No. 3, pp. 551–557, 2000.

Purpose: The purpose of this study was to examine exercise compliance in patients with chronic low back pain (CLBP) after participation in an intensive spine rehabilitation program.

Methods: Exercise behaviors in 122 consecutive subjects with CLBP who completed a program of quota based exercise were examined. Frequency per week of performance of four exercise activities, Oswestry disability scores, and visual analog scale (VAS) scores were assessed at evaluation, 3-month, and 12-month follow-up by patient-completed questionnaires.

Results: Percentage of patients responding to initial, 3-month, and 12-month questionnaires were 100%, 86%, and 71%, respectively. Frequencies of exercise behaviors were compared by Wilcoxon signed-rank test and were found to increase significantly between evaluation and 3 months (P < 0.000), and evaluation and 12-month follow-up (P < 0.000). The percentages of patients reporting three or more times weekly performance of the following activities at evaluation and at three month follow-up, respectively, were: 1) stretching for the back and legs, 35% and 93%; 2) aerobic exercise, 44% and 87%; 3) back-strengthening exercises, 15% and 82%; and, 4) weight training, 6% and 71%. Evaluation and follow-up Oswestry disability and visual analog scale (VAS) scores for back pain were compared using Student’s t-test. Significant improvements (P < 0.000) were noted for each of these scales at 3-month follow-up that were maintained at 12-month follow-up.

Conclusion: It is concluded that exercise behaviors can be increased and maintained in CLBP patients without adversely affecting pain or function.

Most patients with chronic low back pain (CLBP) associate strenuous physical activities with increased pain (34) and avoid activities believed to produce discomfort. Indeed, patients with CLBP are known to be inactive as measured by numerous life function and disability scales and significant levels of physical deconditioning have been documented in this population (1,7,16,17,19,20,23,26). Level of reported pain is known to be affected by numerous nonphysical factors (3,4,6,12,38,43) and is therefore not a reliable or valid measure on which to base activity recommendations. Additionally, significant improvements in physical performance can be achieved in patients with CLBP in spite of continued pain symptoms (35). Nevertheless, health care providers remain reluctant to advise resumption of activities, and frequently reduce therapeutic activity goals in this population due to reports of pain. This may contribute to an unnecessary sedentary state that increases the risk for poor health as well as premature mortality in this population (31,32,40).

Intensive rehabilitation programs for patients with CLBP incorporate progressive training in endurance, flexibility, and strength in order to reverse deconditioning and improve life function. Therapeutic treatment goals are not dependent on level of reported pain, and behavioral techniques are employed to provide positive reinforcement for physical and functional progress. In addition to significant long-lasting improvements in physical parameters in this population after such treatment, improved life function and reduced levels of pain have been demonstrated (13,21,35,37,39).

Unfortunately, whether CLBP patients continue to perform all or part of cardiovascular and back-conditioning regimens after discharge from intensive treatment is infrequently reported. One study reported that 53% of patients with CLBP had “used” a simple elastic gym exercise device 13 months after treatment with intensive, specific exercise, but the frequency of use was not reported (29). Whether post-treatment endurance exercise was recommended or performed was not reported. In another study, only 46% of patients with CLBP continued to perform flexibility exercises 2 months after exercise treatment (9).

Most physicians do not provide physical activity advice to their patients, and only a minority provide exercise prescriptions (14,46). Sometimes supervised exercise programs are prescribed for particular medical reasons, including musculoskeletal and cardiovascular rehabilitation, weight reduction, diabetes control, osteoporosis prevention, and general health. However, investigators have documented poor compliance for both participation in these advised programs and for performance of recommended post-treatment exercise regimens (2,27,29,32,43,44). It seems irrational to provide such expensive exercise treatments if no significant change in exercise habits results. Therefore, when populations undergo exercise treatment, regardless of the diagnoses, attention to exercise-adherence outcomes and identification of factors affecting adherence after treatment seems warranted.

The purpose of this study was to examine exercise compliance in patients with CLBP after participation in an intensive spine rehabilitation program. Specific questions included: 1) Does the frequency per week of performing back stretching, back-strengthening exercise, aerobic exercise, and weight training increase compared with pretreatment levels after aggressive treatment for chronic back pain? 2) If so, are these changes maintained at 12-month follow-up? 3) Does the frequency of exercise at evaluation correlate with other variables? 4) Is the frequency of exercise reported at 12-month follow-up influenced by the intensity of pain and disability noted at 12-month follow-up, or by the changes in pain, disability, and physical performance ability that were observed following completion of rehabilitation (3-month follow-up)?

The Department of Rehabilitation Medicine, Tufts University School of Medicine, Boston, MA

Submitted for publication September 1997.

Accepted for publication January 1999.

Address for correspondence: Carol Hartigan, M.D., The Spine Service, New England Baptist Bone and Joint Institute, 125 Parker Hill Avenue, Boston, MA 02120. E-mail:

©2000The American College of Sports Medicine