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Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?

A Longitudinal Case-Crossover Feasibility Study

Suri, Pradeep MD, MS∗,†,‡,§; Rainville, James MD‡,§; de Schepper, Evelien MD; Martha, Julia MPH; Hartigan, Carol MD‡,§; Hunter, David J. MBBS, PhD‡,||

doi: 10.1097/BRS.0000000000002326

Study Design. Prospective, longitudinal case-crossover study.

Objective. The aim of this study was to determine whether physical activities trigger flare-ups of pain during the course of acute low back pain (LBP).

Summary of Background Data. . There exist no evidence-based estimates for the transient risk of pain flare-ups associated with specific physical activities, during acute LBP.

Methods. Participants with LBP of duration <3 months completed frequent, Internet-based serial assessments at both 3- and 7-day intervals for 6 weeks. At each assessment, participants reported whether they had engaged in specific physical activity exposures, or experienced stress or depression, during the past 24 hours. Participants also reported whether they were currently experiencing a LBP flare-up, defined as “a period of increased pain lasting at least 2 hours, when your pain intensity is distinctly worse than it has been recently.” Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for associations between potential triggers during the past 24 hours, and the risk of LBP flare-ups, using conditional logistic regression.

Results. Of 48 participants followed longitudinally, 30 participants had both case (“flare”) and control periods and contributed data to the case-crossover analysis. There were 81 flare periods and 247 control periods, an average of 11 periods per participant. Prolonged sitting (>6 hours) was the only activity that was significantly associated with flare-ups(OR 4.4, 95% CI 2.0–9.7; P < 0.001). Having either stress or depression was also significantly associated with greater risk of flare-ups (OR 2.5, 95% CI 1.0–6.0; P = 0.04). In multivariable analyses, prolonged sitting (OR 4.2, 95% CI 1.9–9.1; P < 0.001), physical therapy (PT) (OR 0.4, 95% CI 0.1–1.0; P = 0.05), and stress/depression (OR 2.8, 95% CI 1.2–6.7; P = 0.02) were independently and significantly associated with LBP flare-up risk.

Conclusion. Among participants with acute LBP, prolonged sitting (>6 hours) and stress or depression triggered LBP flare-ups. PT was a deterrent of flare-ups.

Level of Evidence: 2

Seattle Epidemiologic Research and Information Center (ERIC) and Division of Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, WA

Department of Rehabilitation Medicine, University of Washington, Seattle, WA

New England Baptist Hospital, Boston, MA

§Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA

Erasmus Medical College, Rotterdam, The Netherlands

||Institute of Bone and Joint Research, Kolling Institute, University of Sydney and Rheumatology Department, Royal North Shore Hospital, Sydney, NSW, Australia.

Address correspondence and reprint requests to Pradeep Suri, MD, MS, VA Puget Sound Health Care System, S-152-ERIC, 1660 S. Columbian Way, Seattle, WA 98108; E-mail:

Received 21 December, 2016

Revised 20 April, 2017

Accepted 26 June, 2017

The manuscript submitted does not contain information about medical device(s)/drug(s).

The Rehabilitation Medicine Scientist Training Program (RMSTP) and the National Institutes of Health (K12 HD 01097) funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, grants, royalties.

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