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Calculated Shard: 192 (from laksa130)

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curl -X POST \
  'http://laksa192.int.ahrefs:8124/' \
  -H 'Content-Type: text/plain' \
  -H 'X-ClickHouse-Database: crawler3' \
  -H 'Authorization: Basic YXBpOg==' \
  -d 'SELECT getAhrefsURLFromUnparsed(src_unparsed) AS found_url, ifNull(toUnixTimestamp(download_stamp), 0) AS crawl_time, ifNull(toUnixTimestamp(props_url_first_seen), 0) AS first_indexed_time, download_http_code AS http_code, src_unparsed AS src_unparsed, src_root_hash AS src_root_hash, history_drop_reason AS history_drop_reason, meta_title AS meta_title, meta_descriptions AS meta_descriptions, attrs_boilerpipe_text AS attrs_boilerpipe_text, attrs_markdown AS attrs_markdown, attrs_readable_markdown AS attrs_readable_markdown, meta_canonical AS meta_canonical FROM crawler3.page_info_local FINAL PREWHERE (src_root_hash, src_unparsed) IN ((getAhrefsRootHashFromUnparsed(getAhrefsUnparsedNoserviceFromURL(\'https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain\')), getAhrefsUnparsedNoserviceFromURL(\'https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain\'))) FORMAT JSONEachRow'

Response:

{"found_url":"https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain","crawl_time":1772998257,"first_indexed_time":1681992746,"http_code":200,"src_unparsed":"com,physio-pedia!www,\/The_Effects_of_Walking_on_Low_Back_Pain s443","src_root_hash":"4378119615441315192","history_drop_reason":null,"meta_title":"The Effects of Walking on Low Back Pain - Physiopedia","meta_descriptions":["Low back pain (LBP) that is not associated with serious or potentially serious causes has been described in the literature as 'non-specific', 'mechanical', 'musculoskeletal', or 'simple' LBP.[1] Non-specific LBP is defined as LBP not attributable to a recognisable specific pathology (eg, infection, tumor, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome).[2]"],"attrs_boilerpipe_text":"Introduction\n[\nedit\n|\nedit source\n]\nLow back pain\n(LBP) that is not associated with serious or potentially serious causes has been described in the literature as '\nnon-specific\n', 'mechanical', 'musculoskeletal', or 'simple' LBP.\n[1]\nNon-specific\nLBP is defined as LBP not attributable to a recognisable specific pathology (eg, infection, tumor, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome).\n[2]\nLBP between the rib cage and gluteal folds\nLBP can be further split into three categories; acute, sub-acute, and\nchronic\n.\n[3]\nAcute is anything that persists for less than 6 weeks.\nSub-acute is anything persisting between 6-12 weeks.\nChronic\nis anything persisting for 12 weeks or more.\nLBP is commonly described to be between the anatomical regions of the ribs and gluteal folds.\n[4]\nAnatomy\n[\nedit\n|\nedit source\n]\nThe\nlumbar spine\ncomprises the lower end of the spinal column between the last\nthoracic\nvertebra (T12) and the first\nsacral vertebra\n(S1). There is a total of five lumbar vertebrae (L1-L5) that are much larger compared to other regions within the vertebral column. These large\nfacets\nhelp support the upper body, as they absorb axial forces (against gravity) delivered from the head, neck, and trunk, and provide protection for the spinal cord from the canal that is formed. The lumbar spine allows for diverse types of trunk motion, including flexion, extension, rotation, and side bending, thus providing further reasons as to why the facets are much larger. Each lumbar segment consists of multiple components; vertebral body, transverse process, super articular process, super articular facet, intervertebral disc, vertebral forearm, the pedicle of the vertebral arch, lamina of the vertebral arch, and a spinous process.\n[5]\nDue to the complex structure of spinal components, discs, intervertebral joints, muscles, and nerves, LBP can present with the same symptoms from different causes.\nEpidemiology\n[\nedit\n|\nedit source\n]\nLBP causes more disability than any other condition, affecting 1 in 10 people and becoming more common with increasing age,\n[1]\nwith rates of 1%–6% in children aged 7–10 years, 18% in adolescents, and a peak prevalence ranging from 28% to 42% in people between 40 years and 69 years.\n[6]\nThe prevalence of LBP is thought to be increasing due to an increasing and aging population\n[7]\nwith estimates of life time prevalence being as high as 84% in the adult population.\n[8]\nOne study that was carried out in 195 countries assessing the incidence, prevalence, and years lived with disability for 354 medical conditions found LBP to be the leading cause of worldwide productivity loss as measured in years, and the top cause of years lived with disability in 126 countries.\n[6]\nIn the United Kingdom (UK), it is estimated that LBP is responsible for 37% of all\nchronic pain\nin men and 44% in women and the total cost of LBP to the UK economy is reckoned to be over £12 billion per year.\n[1]\nRisk factors for LBP are age, sex, height, weight, sedentary lifestyle, depression, anxiety, insomnia, and smoking.\n[10]\nAlthough muscle strain and imbalance, ligament sprain, and soft tissue damage account for almost all LBP, as it is\nnon-specific\n, it often has no identifiable underlying condition or origin.\n[11]\nOffice workers are usually required to sit for long hours working on a computer while spending most of their time in a sitting position. Approximately 34%- 51% of office workers experienced LBP in the preceding 12 months. Occupational groups exposed to '\npoor postures'\nwhile sitting for longer than half a day have a considerably increased risk of experiencing LBP. Subjects with LBP are likely to be in sustained postures and have large and infrequent spinal movements. Prolonged postural loading of the spine while sitting can reduce joint lubrication, fluid content of intervertebral discs, and increased stiffness. Additionally to this, prolonged muscle activation in static sitting may lead to localised muscle tension, muscle strains, muscle fatigue, and other soft-tissue damage, causing impairment of motor coordination and control as well as increased mechanical stress on ligaments and intervertebral discs.\n[12]\nPrevalence of\nwalking in the United Kingdom\n:\nPeople made an average of 236 walking trips and walked an average of 220 miles.\nPeople on average have walked less than in 2019, following a fall in short walks.\nPeople walked 7% farther in 2020 compared to 2019.\n67% of adults in England reported walking at least once a week.\n92% of local authorities had at least 60% of their adult population walking at least once a week.\nThe NHS provides a guide on\n'walking for health'\n, to help motivate the population and help them meet the recommended minimum moderate activity guidelines of 150 minutes.\nPedometer Driven Walking\n[\nedit\n|\nedit source\n]\nExample of a pedometer\nPedometers\nare devices that work by counting the steps someone takes to estimate the distance they have traveled.\n[13]\nPedometers are usually worn at the hip (on the waistband of clothing) and in alignment with the patella although this may not be the case for all pedometers. There are also other ways of tracking steps - many people now have fitness trackers which are attached to the wrist and will also have the ability to count steps.\nInstructions will be included with pedometer devices, and as there are many\ndifferent types\nit is important to check these before usage to ensure that the pedometer is being used as accurately as possible. Some pedometers may also be more complex and do a little bit more than just counting steps such as showing calories burned, activity times, and memory logs.\nWhilst not a pedometer in the traditional sense, the\nNHS\n(National Health Service) also has an application which is free to download called\n'Active 10'\n- this is designed to track walking and will indicate the total amount walked and how much of that was brisk walking. Within the app, there are also options to set goals, achieve milestones, and view progress over the weeks and months. So a pedometer is not the only option to keep a track of walking and daily activity - there are many more apps out there that will do the same thing!\nUsing an app as a pedometer or walking tracker does rely on the individual having a mobile phone and keeping it in their pocket to ensure it tracks all activity whereas a standard pedometer can be used by a wider number of people and may not be as complex.\nDo Pedometers Increase Physical Activity?\n[\nedit\n|\nedit source\n]\nThe NICE (National Institute for Health and Care Excellence) guidelines\non LBP and sciatica in over 16s - published in 2016 and last updated in 2020 - advises self-management and exercise as treatments.\n[1]\nA pedometer would be an easy way of giving someone a tool to help self-manage their activity levels, as long as this was an appropriate choice of exercise for the individual - those with LBP should be encouraged to continue with their regular activities as well.\n[1]\nA three-arm cluster, randomised control trial (RCT) conducted in 2016 with an eventual number of participants at 956 recruited from primary care settings, found that a pedometer-based walking intervention (regardless of whether there was nurse support) increased the step count and physical activity of generally inactive 45-75 year old at a 12 month follow up.\n[14]\nA meta-analysis in 2009 of pedometer-based interventions for activity conducted in 2013 included 32 studies and found using pedometers to have a positive effect on physical activity and this was regardless of age or intervention length.\n[15]\nThe studies had varying interventions from keeping a daily log of steps, completing 10,000 steps, individualized goals, or a combination of strategies.\n[15]\nDo Pedometers Affect LBP?\n[\nedit\n|\nedit source\n]\nAcute Low Back Pain (ALBP)\n[\nedit\n|\nedit source\n]\nThere is arguably less research in relation to ALBP and the effects of using a pedometer. However, a study in 2015, focusing on those with ALBP of 48 hours or less looked at whether 'stay active' advice or 'adjusting activities to pain' had different effects.\n[16]\nParticipants were aged between 18 and 65 and all were provided with a pedometer to track daily steps with the instruction of wearing it at all times during waking hours, they found the pedometer an easily used intervention which increased physical activity, particularly in those with the advice to 'stay active'.\n[16]\nThis study shows that pedometers could have a useful place in treatment alongside other advice and management techniques for those with ALBP despite the study being over a short period of time, and the study size is relatively small.\nChronic Low Back Pain (CLBP)\n[\nedit\n|\nedit source\n]\nAs previously mentioned,\nCLBP\naccounts for a significant amount of chronic pain in individuals of the UK, so interventions that aid in the treatment and management would be beneficial. A recent RCT published in 2021, looked at the effects of a pedometer-driven individualized walking plan compared to standardised care in increasing completion and adherence of physical activity in CLBP management.\n[17]\nWhilst no significant difference was noted in disability or pain, there was an indication that using an individualised, guided pedometer program aided in adherence and participation of physical activity - although relevant measures such as step count were not taken from the standardised care group, so it is unclear if there were any increases in physical activity amongst them.\n[17]\nA previous RCT from 2013, of an internet-based pedometer intervention, did find that in the short-term of 6 months back pain disability had decreased, but at 12 months there was no difference between the group with access to the internet support and the ones utilising the pedometer and standard management only.\n[18]\nAgain, this shows, that whilst pedometer-driven walking can have positive effects in physical activity and adherence, there may need to be further research to explore how positive outcomes can be gained in the long term.\nIt seems that pedometers can be a relatively cheap and accessibly form of intervention and management in individuals with LBP, and this can have greater positive impacts when included with support in one form or another.\n[16]\nBenefits of Walking on Low Back Pain\n[\nedit\n|\nedit source\n]\nThe lower back muscles play an important role in maintaining its stability and movement; two key aspects that are needed when walking.\n[19]\nThese\nmuscles\ncan become deconditioned in those with sedentary lifestyles, leading to weakness over time. This prolonged weakness can increase muscular fatigue, and injury, exaggerating the pain already being experienced.\n[19]\nReduced physical activity can also cause these muscles and the joints of the\nlumbar spine\nto become stiff, which can increase the pressure on the lower back.\n[20]\nWalking has many positive impacts on the lower back\n, which can prevent or reduce these changes occurring in the following ways:\nIncreased blood flow:\nSmall blood vessels and capillaries in the lower back muscles can become constricted following decreased physical activity,\nreducing the blood flow\nto these muscles.\nWalking allows for more movement in these muscles, allowing these capillaries and blood vessels to open up again.\nThis, in turn, increases the blood supply and nutrients to these muscles, improving muscular health and strength and aiding with the healing process.\n[20]\nStretch and contraction of muscles:\nThe movement in the lower back during walking increases the stretch and contraction of the lower back muscles and those in the legs, buttocks, and core, allowing for more flexibility and mobility in this area.\nThis flexibility\nincreases the overall range of motion\nin the lower back, also improving the health and strength of the lower back muscles.\n[21]\nTreatment and Management\n[\nedit\n|\nedit source\n]\nEffect Of Walking On LBP\n[\nedit\n|\nedit source\n]\nCurrent evidence supports the use of walking as a treatment option for LBP. A cross-sectional study from 2017 evaluating the relationship between walking and LBP, consisting of 5,982 adults, found that walking was associated with a reduced risk of LBP.\n[22]\nThe authors also found that the presence of LBP was proportionate to walking frequency, with those who walked more often having reduced LBP. These results are supported by those of a systematic review from 2019 evaluating the effects of walking on those with chronic LBP.\n[23]\nWalking was found to be as effective as other non-pharmacological interventions on pain and disability in short-term (<3 months) and intermediate (3-12 months) follow-ups. These findings allowed for walking to be recommended for managing and treating LBP.\n[23]\nThe effects of walking have been compared to the effects of exercise for LBP. A systematic review from 2019 comparing the two concluded that walking was as effective as exercise for improving pain, disability, quality of life, and fear-avoidance in those with chronic LBP.\n[24]\nMuch like the studies by Kim et al.\n[22]\nand Sitthipornvorakul et al.\n[23]\n, Vanti et al.\n[24]\nrecommend the use of walking as a treatment and management option for LBP.\nInterestingly, a systematic review from 2022, found that people with LBP have altered gait patterns compared with healthy individuals.\n[25]\nThose with LBP were found to walk slower, have reduced stride lengths, greater lumbar paraspinal activation, and reduced thorax\/pelvic coordination.\n[25]\nHowever, the authors were unable to report if these changes were adaptive or maladaptive. Overall, these results indicate that gait re-education may be needed for those with LBP to gain the most benefits from walking.\nA systematic review in 2015 included seven randomised controlled trials involving 869 participants adults with chronic LBP. It compared walking to other non-pharmacological management methods such as usual care, specific strength exercises, medical exercise therapy, or supervised exercise classes. It suggested that walking is the same effective as other management methods while having a lower cost.\n[26]\n. It could be explained by its high accessibility, but does not require training, supervision, or specialised equipment.\n[26]\nOther research supported that walking is as effective as conventional physiotherapy treatment such as lumbar stabilisation and muscle strengthening exercise.\n[27]\n[28]\nA randomised control trial included 48 participants comparing the effect of lumbar stabilisation exercise and walking exercise on LBP. It suggested both interventions significantly reduced LBP, and both interventions show similar results.\n[28]\nAnother randomised control trial compare strengthening exercise to a combined programme of strengthening exercise and walking exercise on chronic LBP. It suggested that both interventions were beneficial but combined exercise programme was more effective for reducing pain levels than the strength exercise.\n[27]\nAnother randomised control trial also supported 44 participants comparing conventional physiotherapy to a combination of conventional physiotherapy with walking exercise. It suggested that a combination of conventional physiotherapy with walking exercise is more effective to reduces pain and kinesiophobia, and improved function in patients with subacute and chronic non-specific LBP.\n[29]\nHow to Use Walking as a Treatment for LBP\n[\nedit\n|\nedit source\n]\n1. Combine with conventional physiotherapy treatment\n[\nedit\n|\nedit source\n]\nWalking is a low-cost intervention, and a combination of physiotherapy with walking is more effective than conventional physiotherapy alone.\n[26]\n[27]\n[29]\nWalking exercise could be educated by physiotherapists alongside their exercise prescription. Recommendations support the use of exercise for at least 15 to 30 minutes most days for those with LBP.\n[30]\nThis can mean gradually building up walking distance and capacity to reduce the risk of injury and allow for the body to adapt to the changes.\n2. Goal setting\n[\nedit\n|\nedit source\n]\nThe use of a\npedometer\nmeans that the patient is able to manage and keep track of their steps whilst walking. The patient might be advised to keep an\n\"activity diary\"\nwhich keeps track of a daily step count and the patient's step goal. This is achieved by calculating the patient's average step count in the first week of activity, and using this as a baseline when deciding a step goal for the second week.\n[31]\nThe use of an activity diary can also help establish the patients' baseline in the first week, which is important in informing their individual goals for rehabilitation.\n[31]\nFor example, use pedometer\/tracking apps (like Active 10) to monitor and then set weekly targets (increase by a certain amount each week\/two weeks for example).\n3. Postural Control\n[\nedit\n|\nedit source\n]\nHaving the\ncorrect walking posture\nis important to allow for more comfortable walking, helping to reduce pain and discomfort. An optimal posture can be achieved using multiple strategies:\nStand up straight:\nThis can be achieved by making yourself as tall as possible, without leaning forwards or backward.\nEnsuring your chin is kept up and your eyes facing forwards allows for reduced strain on your neck and back.\nThese together will allow for a better posture and improved balance.\n[32]\nKeep shoulders back and relaxed:\nRelaxing your shoulders helps relieve tension and allows for a more neutral spine when walking.\nEngage core muscles and keep a neutral pelvis:\nengaging your core and keeping a neutral pelvis prevents arching of the spine and tilting of the pelvis, allowing for a more neutral spine and better posture.\n[33]\nOutcome measures\n[\nedit\n|\nedit source\n]\nThere are a variety of outcome measures that might be used when advising walking as a management strategy for patients with LBP. These might look at:\nPain\nDisability\nPhysical activity\nPain\n[\nedit\n|\nedit source\n]\nVisual Analogue Scale (VAS)\n[\nedit\n|\nedit source\n]\nThe\nVAS (\nVisual Analogue Scale\n)\nis one of the most common outcome measures for LBP.\n[34]\nIt is an example of a subjective PROM (Patient Reported Outcome Measure), where the patient records their pain on a 100mm line- from \"no pain\" at the beginning to the \"worst pain imaginable\". Some types of VAS also use faces to represent pain from \"mild\", \"moderate\" to \"severe\", as shown below.\nPrevious studies have found that the VAS is a \"reliable and valid\" outcome measure for use in a LBP population.\n[36]\nIt has also shown reliability in predicting disability due to LBP.\n[37]\nDisability\n[\nedit\n|\nedit source\n]\nRoland-Morris Disability Questionnaire (RMDQ)\n[\nedit\n|\nedit source\n]\nThe\nRoland-Morris Disability questionnaire (RMDQ)\nis a commonly used PROM, designed to assess a patient's disability in relation to their LBP. It is a 24-item questionnaire that looks at physical functions that the patient feels have been affected, and a higher score represents a higher level of disability due to LBP.\n[38]\nAn example of the RMDQ\n[39]\nA study from 2020 found that the RMDQ had good test-retest reliability and internal consistency reliability in capturing the \"everyday functional impact of low back pain\".\n[40]\nOswestry Disability Index (ODI)\n[\nedit\n|\nedit source\n]\nThe\nOswestry Disability Index (ODI)\nis also commonly used to assess functional disability in patients with LBP.\n[41]\nIt consists of 10 items which are detailed below, as well as the interpretation of the scores.\nOswestry Disability Index (ODI)\n[42]\nInterpretation of ODI scores\n[43]\nThe ODI has been found to be a \"valid and reliable scale suitable for measurement of disability for low back pain\", and in particular showing high test-retest reliability.\n[44]\nA study looked at comparing the ODI and the RMDQ to each other. The study found that the ODI appeared to be better at detecting changes in patients with more severe lower back pain, whereas the RMDQ seemed to have an advantage when measuring patients who had more mild disability.\n[45]\nPhysical activity\n[\nedit\n|\nedit source\n]\nInternational Physical Activity Questionnaire (IPAQ)\n[\nedit\n|\nedit source\n]\nThe International Physical Activity Questionnaire (IPAQ) is formed of two different versions including the IPAQ short-form and the IPAQ long version. Both versions require the patient to recall their physical activity levels in the\npast 7 days.\nBased on these scores, they are placed in one of three categories: low activity levels, moderate activity levels, and high activity levels.\n[46]\nThe\nIPAQ short-form\nconsists of 4 categories where the patient reports how much they participated in the following activities in the past 7 days:\nModerate activity\nVigorous activity\nTime spent walking\nTime spent sitting\nThe IPAQ short-form may be more beneficial for use in a clinical setting due to the shorter\/more accessible nature of the questionnaire for patients.\n[47]\nThe\nIPAQ long version\nassesses physical activity across 5 domains:\nJob-related physical activity\nTransportation physical activity\nHousework, house maintenance, and caring for family\nRecreation, sport, and leisure time\nTime spent walking\nThe IPAQ long version is typically used in research studies or may be used if a more detailed picture of a patient's physical activity levels is preferred.\n[47]\nOverall, the\nIPAQ\nhas been subject to extensive reliability and validity testing across 12 different countries (14 sites) from 2000 as an outcome measure for physical activity.\nSuggestions for Future Clinical Research\n[\nedit\n|\nedit source\n]\nBased on the current literature, walking has been shown to be an effective management strategy for patients with LBP. However, more high-quality RCT’s need to be carried out using a\nvariety of outcome measures,\nincluding physical activity, to further investigate walking as an effective management strategy for LBP.  \nIn order to strengthen the current evidence around this topic, further research could be carried out on how to ensure the\nlong term\neffects\nof pedometer-based intervention. It would also be valuable to investigate whether added interventions might be necessary in aiding supportive positive outcomes long-term.\nThe current NICE guidelines for LBP and sciatica were published in 2016 and updated in 2020 for pharmacological interventions. However, the advice for “non-pharmacological interventions” last had an evidence review in\n2016.\nTherefore, it may be beneficial for a reassessment based on new evidence, in which guidelines around walking could be evaluated.\nReferences\n[\nedit\n|\nedit source\n]\n↑\nJump up to:\n1.0\n1.1\n1.2\n1.3\n1.4\nDe Campos TF.\nLow back pain and sciatica in over 16s: assessment and management NICE Guideline [NG59]\n. J Physiother. 2017 Apr 1;63(2):120.\n↑\nBalagué F, Mannion AF, Pellisé F, Cedraschi C.\nNon-specific low back pain.\nLancet. 2012 Feb 4;379(9814):482-91.\n↑\nBurton AK, Balagué F, Cardon G, Eriksen HR, Henrotin Y, Lahad A, Leclerc A, Müller G, Van Der Beek AJ, COST B13 Working Group on Guidelines for Prevention in Low Back Pain. European guidelines for prevention in low back pain: November 2004. European Spine Journal. 2006 Mar;15(Suppl 2):s136.\n↑\nFirestein GS, Budd RC, Gabriel SE, McInnes IB, O'Dell JR.\nKelley and Firestein's textbook of rheumatology.\nElsevier Health Sciences; 2016 Jun 21.\n↑\nSassack B, Carrier J.\nAnatomy, Back, Lumbar Spine.\n[online] StatPerals [Intenet] 2022; August 25. Available from:\nhttps:\/\/www.ncbi.nlm.nih.gov\/books\/NBK557616\/\n[accessed 25\/4\/2022]\n↑\nJump up to:\n6.0\n6.1\nKnezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP.\nLow back pain\n. Lancet. 2021 Jul 3;398(10294):78-92.\n↑\nBuchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, Croft P, Hartvigsen J, Cherkin D, Foster NE, Maher CG.\nLow back pain: a call for action.\nLancet. 2018 Jun 9;391(10137):2384-8.\n↑\nCasiano VE, Sarwan G, Dydyk AM, Varacallo M.\nBack Pain.\nStatPearls [Internet]. 2022 Feb 22. Available from: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK538173\/ [accessed 25\/4\/2023]\n↑\nWu A, March L, Zheng X, Huang J, Wang X, Zhao J, Blyth F, Smith E, Buchbinder R, Hoy D.\nGlobal low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017.\nAnn Transl Med 2020; 8(6): 299.\n↑\nSharp C. Musculoskeletal conditions and disorders in P.L. Jacobs (Ed)\nNSCA’s essentials of training special populations.\nChampaign, IL: Human Kinetics. 2018\n↑\nSoloman J. Low back pain. In: J.S. Skinner, C.X. Bryant, S. Merrill, & D.J. Green (Eds), American Council on Exercise medical exercise specialist manual. San Diego, CA: American Council on Exercise.2015\n↑\nWaongenngarm P, Areerak K, Janwantanakul P. The effects of breaks on low back pain, discomfort, and work productivity in office workers: A systematic review of randomized and non-randomized controlled trials. Applied ergonomics. 2018 Apr 1;68:230-9.\n↑\nTudor-Locke C, Lutes L.\nWhy do pedometers work?: a reflection upon the factors related to successfully increasing physical activity.\nSports Med. 2009;39(12):981-93.\n↑\nHarris T, Kerry SM, Limb ES, Victor CR, Iliffe S, Ussher M, Whincup PH, Ekelund U, Fox-Rushby J, Furness C, Anokye N.\nEffect of a Primary Care Walking Intervention with and without Nurse Support on Physical Activity Levels in 45-to 75-Year-Olds: The P pedometer A and C consultation E valuation (PACE-UP) Cluster Randomised Clinical Trial.\nPLoS Medicine. 2017 Jan 3;14(1):e1002210.\n↑\nJump up to:\n15.0\n15.1\nKang M, Marshall SJ, Barreira TV, Lee JO.\nEffect of pedometer-based physical activity interventions: a meta-analysis.\nRes Q Exerc Sport. 2009 Sep 1;80(3):648-55.\n↑\nJump up to:\n16.0\n16.1\n16.2\nOlaya-Contreras P, Styf J, Arvidsson D, Frennered K, Hansson T.\nThe effect of the stay active advice on physical activity and on the course of acute severe low back pain.\nBMC Sports Sci Med Rehabil. 2015 Dec;7(1):1-9.\n↑\nJump up to:\n17.0\n17.1\nLang AE, Hendrick PA, Clay L, Mondal P, Trask CM, Bath B, Penz ED, Stewart SA, Baxter GD, Hurley DA, McDonough SM.\nA randomized controlled trial investigating the effects of an individualized pedometer-driven walking program on chronic low back pain.\nBMC Musculoskelet Disord. 2021 Dec;22(1):1-4.\n↑\nKrein SL, Kadri R, Hughes M, Kerr EA, Piette JD, Holleman R, Kim HM, Richardson CR.\nPedometer-based internet-mediated intervention for adults with chronic low back pain: randomized controlled trial.\nJMIR. 2013 Aug 22;15(8):e2605.\n↑\nJump up to:\n19.0\n19.1\nValdivieso P, Franchi MV, Gerber C, Flück M.\nDoes a better perfusion of deconditioned muscle tissue release chronic Low Back pain?\n. Front Med. 2018 Mar 20;5:77.\n↑\nJump up to:\n20.0\n20.1\nGordon R, Bloxham S.\nA systematic review of the effects of exercise and physical activity on non-specific chronic low back pain.\nHealthcare 2016 Apr 25; 4(2):22.\n↑\nTillotson C. How to walk correctly and fix your lower back pain. Take the Five Easy Steps. Available from:\nhttp:\/\/www.youtube.com\/watch?v=B9jt4d_828g\n[accessed 26\/4\/2023]\n↑\nJump up to:\n22.0\n22.1\nKim H, Min TJ, Kang SH, Kim DK, Seo KM, Lee SY.\nAssociation between walking and low back pain in the Korean population: a cross-sectional study.\nAnn Rehabil Med. 2017 Oct 31;41(5):786-92.\n↑\nJump up to:\n23.0\n23.1\n23.2\nSitthipornvorakul E, Klinsophon T, Sihawong R, Janwantanakul P.\nThe effects of walking intervention in patients with chronic low back pain: A meta-analysis of randomized controlled trials.\nMusculoskelet Sci Pract. 2018 Apr 1;34:38-46.\n↑\nJump up to:\n24.0\n24.1\nVanti C, Andreatta S, Borghi S, Guccione A, Pillastrini P, Bertozzi L.\nThe effectiveness of walking versus exercise on pain and function in chronic low back pain: a systematic review and meta-analysis of randomized trials.\nDisabil Rehabil. 2019 Mar 13;41(6):622-32.\n↑\nJump up to:\n25.0\n25.1\nSmith J, Stabbert H, Bagwell J, Teng H, Wade V, Lee S.\nDo people with low back pain walk differently? A systematic review and meta-analysis.\nJ Sport Health Sci. 2022 Jul;11(4):450-465.\n↑\nJump up to:\n26.0\n26.1\n26.2\nLawford BJ, Walters J, Ferrar K.\nDoes walking improve disability status, function, or quality of life in adults with chronic low back pain? A systematic review.\nClin Rehabil. 2016 Jun;30(6):523-36.\n↑\nJump up to:\n27.0\n27.1\n27.2\nLee JS, Kang SJ.\nThe effects of strength exercise and walking on lumbar function, pain level, and body composition in chronic back pain patients.\nJ Exerc Rehabil. 2016 Oct;12(5):463-70.\n↑\nJump up to:\n28.0\n28.1\nSuh JH, Kim H, Jung GP, Ko JY, Ryu JS.\nThe effect of lumbar stabilization and walking exercises on chronic low back pain: A randomized controlled trial.\nMedicine (Baltimore). 2019 Jun;98(26):e16173.\n↑\nJump up to:\n29.0\n29.1\nYilmaz Yelvar GD, Çırak Y, Dalkılınç M, Parlak Demir Y, Guner Z, Boydak A.\nIs physiotherapy integrated virtual walking effective on pain, function, and kinesiophobia in patients with non-specific low-back pain? Randomised controlled trial.\nEur Spine J. 2017 Feb;26(2):538-45.\n↑\nNorris MK, Fox FS, Lee C, Wang E, Green K, Yan H, Dieli-Conwright CM.\nNarrowing the gap for minority cancer survivors: exercise oncology in the past, present, and future.\nJournal of Clinical Exercise Physiology. 2020 Dec;9(4):155-70.\n↑\nJump up to:\n31.0\n31.1\nNicolson PJ, Bennell KL, Dobson FL, Van Ginckel A, Holden MA, Hinman RS.\nInterventions to increase adherence to therapeutic exercise in older adults with low back pain and\/or hip\/knee osteoarthritis: a systematic review and meta-analysis.\nBr J Sports Med. 2017 May 1;51(10):791-9.\n↑\nPickle NT, Grabowski AM, Auyang AG, Silverman AK.\nThe functional roles of muscles during sloped walking.\nJ Biomech. 2016 Oct 3;49(14):3244-51.\n↑\nJung J, Yu J, Kang H.\nDifferences in trunk muscle activities and ratios between unstable supine and prone bridging exercises in individuals with low back pain\n. Journal of Physical Therapy Science. 2012;24(9):889-92.\n↑\nChiarotto A, Maxwell LJ, Ostelo RW, Boers M, Tugwell P, Terwee CB.\nMeasurement properties of visual analogue scale, numeric rating scale, and pain severity subscale of the brief pain inventory in patients with low back pain: a systematic review.\nJ Pain. 2019 Mar 1;20(3):245-63.\n↑\nWeCapable.com. Visual Analogue Scale for pain (VAS): Scoring pain on 100mm line. Disability information. 2022. Available from:\nhttps:\/\/wecapable.com\/vas-pain-scale-100mm-line\/\n[accessed 27\/5\/2023]  \n↑\nOlaogun MO, Adedoyin RA, Ikem IC, Anifaloba OR.\nReliability of rating low back pain with a visual analog scale and a semantic differential scale.\nPhysiotherapy Theory and Practice. 2004 Jan 1;20(2):135-42.\n↑\nShafshak TS, Elnemr R.\nThe visual analog scale versus numerical rating scale in measuring pain severity and predicting disability in low back pain.\nJ Clin Rheumatol. 2021 Oct 1;27(7):282-5.\n↑\nChiarotto A, Maxwell LJ, Terwee CB, Wells GA, Tugwell P, Ostelo RW.\nRoland-Morris Disability Questionnaire and Oswestry Disability Index: which has better measurement properties for measuring physical functioning in nonspecific low back pain? Systematic review and meta-analysis\n. Phys Ther. 2016 Oct 1;96(10):1620-37.\n↑\nPrimePhysio. Roland-Morris Disability Questionnaire. Orthopaedic manual therapy certificate. Available from:\nhttps:\/\/www.primephysio.com\/forum\/_omtc\/roland-morris-disability-questionnaire-rmdq\n[accessed 27\/5\/ 2023]  \n↑\nBurbridge C, Randall J, Abraham L, Bush E.\nMeasuring the impact of chronic low back pain on everyday functioning: content validity of the Roland Morris disability questionnaire.\nJ Patient Rep Outcomes. 2020 Dec;4(1):1-5.\n↑\nFairbank JC, Pynsent PB.\nThe Oswestry Disability Index.\nSpine (Phila Pa 1976). 2000 Nov 15;25(22):2940-52\n↑\nHaegg O.\nOswestry Disability Index.\nEncyclopedia of Pain. 2013 Edition. Available from:\nhttps:\/\/link.springer.com\/referenceworkentry\/10.1007\/978-3-642-28753-4_3021#howtocite\n[accessed 27\/5\/2023]  \n↑\nJalil N, Sulaiman Z, Awang M, Omar M.\nRetrospective Review of Outcomes of a Multimodal Chronic Pain Service in a Major Teaching Hospital: A Preliminary Experience in Universiti Sains Malaysia.\nMalays J Med Sci. 2009; 16(4): 55-65.\n↑\nLee CP, Fu TS, Liu CY, Hung CI.\nPsychometric evaluation of the Oswestry Disability Index in patients with chronic low back pain: factor and Mokken analyses.\nHealth Qual Life Outcomes. 2017 Dec;15(1):1-7.\n↑\nFairbank J, Pynsent P.\nThe Oswestry Disability Index\n. Spine 2000; 25(22):2940-53.\n↑\nForde C.\nScoring the International Physical activity questionnaire (IPAQ).\nExercise prescription for the prevention and treatment of disease, University of Dublin 2018; 3. Available from:\nhttps:\/\/ugc.futurelearn.com\/uploads\/files\/bc\/c5\/bcc53b14-ec1e-4d90-88e3-1568682f32ae\/IPAQ_PDF.pdf\n[accessed 27\/5\/2023]\n↑\nJump up to:\n47.0\n47.1\nCraig C, Marshall A, Sjöström M, Bauman A, Booth M, Ainsworth B, Pratt M, Ekelund U, Yngve A, Sallis J, Oja P.\nInternational physical activity questionnaire: 12-country reliability and validity.\nMed Sci Sports Exerc. 2003 Aug 1;35(8):1381-95.","attrs_markdown":"![Physiopedia logo](https:\/\/www.physio-pedia.com\/skins\/PhysiopediaSkin\/resources\/images\/PP-logo-horizontal.png)\n\nToggle navigation\n\n- [pPhysiopedia](https:\/\/www.physio-pedia.com\/home \"Physiopedia\")\n\n- [pPhysiopedia](https:\/\/www.physio-pedia.com\/home \"Physiopedia\")\n- [About](https:\/\/www.physio-pedia.com\/Physiopedia:About)\n- [News](https:\/\/members.physio-pedia.com\/plus-news\/)\n- [Contribute](https:\/\/www.physio-pedia.com\/Contribute)\n- [Courses](https:\/\/members.physio-pedia.com\/learn\/?utm_source=physiopedia&utm_medium=top_nav_courses&utm_campaign=ongoing_internal)\n- [PAI](https:\/\/members.physio-pedia.com\/physiopedia-ai-assistant\/?utm_source=physiopedia&utm_medium=top_nav_pai&utm_campaign=ongoing_internal)\n- [Pages](https:\/\/www.physio-pedia.com\/Articles)\n- [Shop](https:\/\/shop.physio-pedia.com\/)\n- [Contact](https:\/\/members.physio-pedia.com\/pp-contact-us\/)\n- [Login](https:\/\/www.physio-pedia.com\/index.php?title=Special:UserLogin&returnto=The+Effects+of+Walking+on+Low+Back+Pain)\n\n[pPhysiopedia](https:\/\/www.physio-pedia.com\/home \"Physiopedia\")\n\n- [About](https:\/\/www.physio-pedia.com\/Physiopedia:About)\n- [News](https:\/\/members.physio-pedia.com\/plus-news\/)\n- [Contribute](https:\/\/www.physio-pedia.com\/Contribute)\n- [Courses](https:\/\/members.physio-pedia.com\/learn\/?utm_source=physiopedia&utm_medium=mobile_nav_courses&utm_campaign=ongoing_internal)\n- [PAI](https:\/\/members.physio-pedia.com\/physiopedia-ai-assistant\/?utm_source=physiopedia&utm_medium=mobile_nav_pai&utm_campaign=ongoing_internal)\n- [Pages](https:\/\/www.physio-pedia.com\/Articles)\n- [Shop](https:\/\/shop.physio-pedia.com\/)\n- [Contact](https:\/\/members.physio-pedia.com\/pp-contact-us\/)\n\n[p](https:\/\/www.physio-pedia.com\/home \"Physiopedia\") [\\+](https:\/\/members.physio-pedia.com\/?utm_source=physiopedia&utm_medium=mobile_logo&utm_campaign=ongoing_internal \"Plus\")\n\n- [Contents](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#contents)\n- [Editors](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#editors)\n- [Categories](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#categories)\n- [Cite](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#citation)\n\n## Contents\n- [1 Introduction](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Introduction)\n- [2 Anatomy](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Anatomy)\n- [3 Epidemiology](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Epidemiology)\n- [4 Pedometer Driven Walking](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Pedometer_Driven_Walking)\n  - [4\\.1 Do Pedometers Increase Physical Activity?](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Do_Pedometers_Increase_Physical_Activity?)\n  - [4\\.2 Do Pedometers Affect LBP?](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Do_Pedometers_Affect_LBP?)\n    - [4\\.2.1 Acute Low Back Pain (ALBP)](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Acute_Low_Back_Pain_\\(ALBP\\))\n    - [4\\.2.2 Chronic Low Back Pain (CLBP)](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Chronic_Low_Back_Pain_\\(CLBP\\))\n- [5 Benefits of Walking on Low Back Pain](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Benefits_of_Walking_on_Low_Back_Pain)\n- [6 Treatment and Management](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Treatment_and_Management)\n  - [6\\.1 Effect Of Walking On LBP](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Effect_Of_Walking_On_LBP)\n  - [6\\.2 How to Use Walking as a Treatment for LBP](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#How_to_Use_Walking_as_a_Treatment_for_LBP)\n    - [6\\.2.1 1\\. Combine with conventional physiotherapy treatment](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#1._Combine_with_conventional_physiotherapy_treatment)\n    - [6\\.2.2 2\\. Goal setting](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#2._Goal_setting)\n    - [6\\.2.3 3\\. Postural Control](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#3._Postural_Control)\n- [7 Outcome measures](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Outcome_measures)\n  - [7\\.1 Pain](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Pain)\n    - [7\\.1.1 Visual Analogue Scale (VAS)](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Visual_Analogue_Scale_\\(VAS\\))\n  - [7\\.2 Disability](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Disability)\n    - [7\\.2.1 Roland-Morris Disability Questionnaire (RMDQ)](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Roland-Morris_Disability_Questionnaire_\\(RMDQ\\))\n    - [7\\.2.2 Oswestry Disability Index (ODI)](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Oswestry_Disability_Index_\\(ODI\\))\n  - [7\\.3 Physical activity](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Physical_activity)\n    - [7\\.3.1 International Physical Activity Questionnaire (IPAQ)](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#International_Physical_Activity_Questionnaire_\\(IPAQ\\))\n- [8 Suggestions for Future Clinical Research](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Suggestions_for_Future_Clinical_Research)\n- [9 References](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#References)\n\n**Original Editor** \\- [Toby Stowe](https:\/\/www.physio-pedia.com\/User:Toby_Stowe \"User:Toby Stowe\") as part of the [Nottingham University Spinal Rehabilitation Project](https:\/\/www.physio-pedia.com\/Nottingham_University_Spinal_Rehabilitation_Project \"Nottingham University Spinal Rehabilitation Project\")  \n**Top Contributors** -\n\n[Toby Stowe](https:\/\/www.physio-pedia.com\/User:Toby_Stowe \"User:Toby Stowe\")\n\n,\n\n[Angeliki Chorti](https:\/\/www.physio-pedia.com\/User:Angeliki_Chorti \"User:Angeliki Chorti\")\n\n,\n\n[Khloud Shreif](https:\/\/www.physio-pedia.com\/User:Khloud_Shreif \"User:Khloud Shreif\")\n\nand\n\n[Cindy John-Chu](https:\/\/www.physio-pedia.com\/User:Cindy_John-Chu \"User:Cindy John-Chu\")\n\nWhen refering to evidence in academic writing, you should always try to reference the primary (original) source. That is usually the journal article where the information was first stated. In most cases Physiopedia articles are a secondary source and so should not be used as references. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article).\n\nIf you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement.\n\n[Cite article](https:\/\/www.physio-pedia.com\/index.php?title=Special%3ACiteThisPage&wpFormIdentifier=titleform&page=The%20Effects%20of%20Walking%20on%20Low%20Back%20Pain)\n\n# The Effects of Walking on Low Back Pain\nJump to:[navigation](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#mw-navigation), [search](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#p-search)\n\n**Original Editor** \\- [Toby Stowe](https:\/\/www.physio-pedia.com\/User:Toby_Stowe \"User:Toby Stowe\") as part of the [Nottingham University Spinal Rehabilitation Project](https:\/\/www.physio-pedia.com\/Nottingham_University_Spinal_Rehabilitation_Project \"Nottingham University Spinal Rehabilitation Project\")  \n**Top Contributors** -\n\n[Toby Stowe](https:\/\/www.physio-pedia.com\/User:Toby_Stowe \"User:Toby Stowe\")\n\n,\n\n[Angeliki Chorti](https:\/\/www.physio-pedia.com\/User:Angeliki_Chorti \"User:Angeliki Chorti\")\n\n,\n\n[Khloud Shreif](https:\/\/www.physio-pedia.com\/User:Khloud_Shreif \"User:Khloud Shreif\")\n\nand\n\n[Cindy John-Chu](https:\/\/www.physio-pedia.com\/User:Cindy_John-Chu \"User:Cindy John-Chu\")\n\n## Contents\n- [1 Introduction](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Introduction)\n- [2 Anatomy](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Anatomy)\n- [3 Epidemiology](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Epidemiology)\n- [4 Pedometer Driven Walking](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Pedometer_Driven_Walking)\n  - [4\\.1 Do Pedometers Increase Physical Activity?](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Do_Pedometers_Increase_Physical_Activity?)\n  - [4\\.2 Do Pedometers Affect LBP?](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Do_Pedometers_Affect_LBP?)\n    - [4\\.2.1 Acute Low Back Pain (ALBP)](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Acute_Low_Back_Pain_\\(ALBP\\))\n    - [4\\.2.2 Chronic Low Back Pain (CLBP)](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Chronic_Low_Back_Pain_\\(CLBP\\))\n- [5 Benefits of Walking on Low Back Pain](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Benefits_of_Walking_on_Low_Back_Pain)\n- [6 Treatment and Management](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Treatment_and_Management)\n  - [6\\.1 Effect Of Walking On LBP](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Effect_Of_Walking_On_LBP)\n  - [6\\.2 How to Use Walking as a Treatment for LBP](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#How_to_Use_Walking_as_a_Treatment_for_LBP)\n    - [6\\.2.1 1\\. Combine with conventional physiotherapy treatment](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#1._Combine_with_conventional_physiotherapy_treatment)\n    - [6\\.2.2 2\\. Goal setting](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#2._Goal_setting)\n    - [6\\.2.3 3\\. Postural Control](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#3._Postural_Control)\n- [7 Outcome measures](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Outcome_measures)\n  - [7\\.1 Pain](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Pain)\n    - [7\\.1.1 Visual Analogue Scale (VAS)](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Visual_Analogue_Scale_\\(VAS\\))\n  - [7\\.2 Disability](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Disability)\n    - [7\\.2.1 Roland-Morris Disability Questionnaire (RMDQ)](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Roland-Morris_Disability_Questionnaire_\\(RMDQ\\))\n    - [7\\.2.2 Oswestry Disability Index (ODI)](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Oswestry_Disability_Index_\\(ODI\\))\n  - [7\\.3 Physical activity](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Physical_activity)\n    - [7\\.3.1 International Physical Activity Questionnaire (IPAQ)](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#International_Physical_Activity_Questionnaire_\\(IPAQ\\))\n- [8 Suggestions for Future Clinical Research](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#Suggestions_for_Future_Clinical_Research)\n- [9 References](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#References)\n\nRelated online courses on \\+Physiopedia Plus\n\n[![](https:\/\/swiftype-ss.imgix.net\/https%3A%2F%2Fmembers.physio-pedia.com%2Fwp-content%2Fuploads%2F2022%2F03%2FManaging-Low-Back-Pain-with-Integrative-Lifestyle-Medicine-Programme-300x169.jpeg?ixlib=rb-1.1.0&h=320&fit=clip&dpr=2.0&s=42d4ba6f776e567058e73fd1be29b473) Online Course: Managing Low Back Pain with Integrative Lifestyle Medicine Programme *Low* *Back* *Pain* with Integrative Lifestyle Medicine Programme Use a holistic approach to empower your clients and provide holistic care treatment for chronic LBP Start course 11-13 hours - - - - Powered by *Physiopedia* Course instructor Z Altug Ziya \"Z\" is a physical therapist specialising •](https:\/\/members.physio-pedia.com\/learn\/managing-low-back-pain-with-integrative-lifestyle-medicine-programme-promopage\/?utm_source=physiopedia&utm_medium=related_courses_mobile&utm_campaign=ongoing_internal)   [![](https:\/\/swiftype-ss.imgix.net\/https%3A%2F%2Fmembers.physio-pedia.com%2Fwp-content%2Fuploads%2F2022%2F03%2FLifestyle-Medicine-and-Office-Ergonomic-Strategies-for-Managing-Low-Back-Pain-300x169.jpg?ixlib=rb-1.1.0&h=320&fit=clip&dpr=2.0&s=04f5116ad2ac7ee3f46ebcbec48bede5) Online Course: Lifestyle Medicine and Office Ergonomic Strategies for Managing Low Back Pain Lifestyle Medicine and Office Ergonomic Strategies for Managing *Low* *Back* *Pain* A holistic approach to managing LBP for the office worker Start course 1-1.5 hours - - - - Powered by *Physiopedia* Course instructor Z Altug Ziya \"Z\" is a physical therapist specialising in lifestyle medicine Summarising •](https:\/\/members.physio-pedia.com\/learn\/lifestyle-medicine-and-office-ergonomic-strategies-for-managing-low-back-pain-promopage\/?utm_source=physiopedia&utm_medium=related_courses_mobile&utm_campaign=ongoing_internal)   [![](https:\/\/swiftype-ss.imgix.net\/https%3A%2F%2Fmembers.physio-pedia.com%2Fwp-content%2Fuploads%2F2022%2F03%2FIntroduction-to-Managing-Chronic-Low-Back-Pain-with-Integrative-Lifestyle-Medicine-300x169.jpeg?ixlib=rb-1.1.0&h=320&fit=clip&dpr=2.0&s=2d7777166658f0d7e9de90983dbac631) Online Course: Introduction to Managing Chronic Low Back Pain with Integrative Lifestyle Medicine Introduction to Managing Chronic *Low* *Back* *Pain* with Integrative Lifestyle Medicine Learn the basics of holistic treatment for chronic LBP Start course 1-1.5 hours - - - - Powered by *Physiopedia* Course instructor Z Altug Ziya \"Z\" is a physical therapist specialising in lifestyle medicine Summarising •](https:\/\/members.physio-pedia.com\/learn\/introduction-to-managing-chronic-low-back-pain-with-integrative-lifestyle-medicine-promopage\/?utm_source=physiopedia&utm_medium=related_courses_mobile&utm_campaign=ongoing_internal)   [![](https:\/\/swiftype-ss.imgix.net\/https%3A%2F%2Fmembers.physio-pedia.com%2Fwp-content%2Fuploads%2F2022%2F03%2FLifestyle-Medicine-Exercise-and-Nutrition-for-Managing-Chronic-Low-Back-Pain-300x169.jpeg?ixlib=rb-1.1.0&h=320&fit=clip&dpr=2.0&s=b3b5d69069dd6a8e9cb80b3da43e418c) Online Course: Lifestyle Medicine, Exercise and Nutrition for Managing Chronic Low Back Pain Lifestyle Medicine, Exercise and Nutrition for Managing Chronic *Low* *Back* *Pain* Enrich your knowledge of integrative exercises and nutrition and confidently prescribe holistic treatments for chronic LBP Start course 1-1.5 hours - - - - Powered by *Physiopedia* Course instructor Z Altug Ziya \"Z\" is a physical •](https:\/\/members.physio-pedia.com\/learn\/lifestyle-medicine-exercise-and-nutrition-for-managing-chronic-low-back-pain-promopage\/?utm_source=physiopedia&utm_medium=related_courses_mobile&utm_campaign=ongoing_internal)   [![](https:\/\/swiftype-ss.imgix.net\/https%3A%2F%2Fmembers.physio-pedia.com%2Fwp-content%2Fuploads%2F2022%2F01%2Fsleep-wellness-300x169.jpg?ixlib=rb-1.1.0&h=320&fit=clip&dpr=2.0&s=978d68d67992db07f935438abf596a87) Online Course: Lifestyle Medicine, Sleep Hygiene and Psychological Well-Being for Managing Chronic Low Back Pain Lifestyle Medicine, Sleep Hygiene and Psychological Well-Being for Managing Chronic *Low* *Back* *Pain* Break the sleep-*pain*\\-stress cycle for your patients with chronic *low* *back* *pain* using integrative exercises and whole-person treatments Start course 1-1.5 hours - - - - Powered by *Physiopedia* Course instructor Z •](https:\/\/members.physio-pedia.com\/learn\/lifestyle-medicine-sleep-hygiene-and-psychological-well-being-for-managing-chronic-low-back-pain-promopage\/?utm_source=physiopedia&utm_medium=related_courses_mobile&utm_campaign=ongoing_internal)\n\n[![](https:\/\/members.physio-pedia.com\/wp-content\/uploads\/2022\/03\/Managing-Low-Back-Pain-with-Integrative-Lifestyle-Medicine-Programme.jpeg)ONLINE COURSE Managing Low Back Pain with Integrative Lifestyle Medicine Programme Professional development from Physiopedia Plus](https:\/\/members.physio-pedia.com\/learn\/managing-low-back-pain-with-integrative-lifestyle-medicine-programme-promopage\/?utm_source=physiopedia&utm_medium=related_courses_normal_vertical&utm_campaign=ongoing_internal)\n\n[![](https:\/\/members.physio-pedia.com\/wp-content\/uploads\/2022\/03\/Lifestyle-Medicine-and-Office-Ergonomic-Strategies-for-Managing-Low-Back-Pain.jpg)ONLINE COURSE Lifestyle Medicine and Office Ergonomic Strategies for Managing Low Back Pain Get your CEUs \/ CPD points from Physiopedia](https:\/\/members.physio-pedia.com\/learn\/lifestyle-medicine-and-office-ergonomic-strategies-for-managing-low-back-pain-promopage\/?utm_source=physiopedia&utm_medium=related_courses_normal_vertical&utm_campaign=ongoing_internal)\n\n[![](https:\/\/members.physio-pedia.com\/wp-content\/uploads\/2022\/03\/Introduction-to-Managing-Chronic-Low-Back-Pain-with-Integrative-Lifestyle-Medicine.jpeg)ONLINE COURSE Introduction to Managing Chronic Low Back Pain with Integrative Lifestyle Medicine AI supported learning powered by Physiopedia](https:\/\/members.physio-pedia.com\/learn\/introduction-to-managing-chronic-low-back-pain-with-integrative-lifestyle-medicine-promopage\/?utm_source=physiopedia&utm_medium=related_courses_normal_vertical&utm_campaign=ongoing_internal)\n\n[![](https:\/\/members.physio-pedia.com\/wp-content\/uploads\/2022\/03\/Managing-Low-Back-Pain-with-Integrative-Lifestyle-Medicine-Programme.jpeg)ONLINE COURSE Managing Low Back Pain with Integrative Lifestyle Medicine Programme Professional development from Physiopedia Plus](https:\/\/members.physio-pedia.com\/learn\/managing-low-back-pain-with-integrative-lifestyle-medicine-programme-promopage\/?utm_source=physiopedia&utm_medium=related_courses_mobile_vertical&utm_campaign=ongoing_internal)\n\n## Introduction\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=1 \"Edit section: Introduction\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=1 \"Edit section: Introduction\")\\]\n[Low back pain](https:\/\/www.physio-pedia.com\/Low_Back_Pain) (LBP) that is not associated with serious or potentially serious causes has been described in the literature as '[non-specific](https:\/\/www.physio-pedia.com\/Non_Specific_Low_Back_Pain)', 'mechanical', 'musculoskeletal', or 'simple' LBP.[\\[1\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1) [Non-specific](https:\/\/www.physio-pedia.com\/Non_Specific_Low_Back_Pain) LBP is defined as LBP not attributable to a recognisable specific pathology (eg, infection, tumor, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome).[\\[2\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-2)\n\n[![](https:\/\/www.physio-pedia.com\/images\/thumb\/3\/3e\/Lower_back_pain.png\/200px-Lower_back_pain.png)](https:\/\/www.physio-pedia.com\/File:Lower_back_pain.png)\n\nLBP between the rib cage and gluteal folds\n\nLBP can be further split into three categories; acute, sub-acute, and [chronic](https:\/\/www.physio-pedia.com\/Chronic_Low_Back_Pain).[\\[3\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-3)\n\n1. Acute is anything that persists for less than 6 weeks.\n2. Sub-acute is anything persisting between 6-12 weeks.\n3. [Chronic](https:\/\/www.physio-pedia.com\/Chronic_Low_Back_Pain) is anything persisting for 12 weeks or more.\n\nLBP is commonly described to be between the anatomical regions of the ribs and gluteal folds.[\\[4\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:1-4)\n\n## Anatomy\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=2 \"Edit section: Anatomy\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=2 \"Edit section: Anatomy\")\\]\nThe [lumbar spine](https:\/\/www.physio-pedia.com\/Lumbar_Anatomy \"Lumbar Anatomy\") comprises the lower end of the spinal column between the last [thoracic](https:\/\/www.physio-pedia.com\/Thoracic_Anatomy \"Thoracic Anatomy\") vertebra (T12) and the first [sacral vertebra](https:\/\/www.physio-pedia.com\/Sacrum \"Sacrum\") (S1). There is a total of five lumbar vertebrae (L1-L5) that are much larger compared to other regions within the vertebral column. These large [facets](https:\/\/www.physio-pedia.com\/Facet_Joints \"Facet Joints\") help support the upper body, as they absorb axial forces (against gravity) delivered from the head, neck, and trunk, and provide protection for the spinal cord from the canal that is formed. The lumbar spine allows for diverse types of trunk motion, including flexion, extension, rotation, and side bending, thus providing further reasons as to why the facets are much larger. Each lumbar segment consists of multiple components; vertebral body, transverse process, super articular process, super articular facet, intervertebral disc, vertebral forearm, the pedicle of the vertebral arch, lamina of the vertebral arch, and a spinous process.[\\[5\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-5)\n\nDue to the complex structure of spinal components, discs, intervertebral joints, muscles, and nerves, LBP can present with the same symptoms from different causes.\n\n## Epidemiology\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=3 \"Edit section: Epidemiology\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=3 \"Edit section: Epidemiology\")\\]\nLBP causes more disability than any other condition, affecting 1 in 10 people and becoming more common with increasing age, [\\[1\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1)with rates of 1%–6% in children aged 7–10 years, 18% in adolescents, and a peak prevalence ranging from 28% to 42% in people between 40 years and 69 years.[\\[6\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:3-6) The prevalence of LBP is thought to be increasing due to an increasing and aging population [\\[7\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-7) with estimates of life time prevalence being as high as 84% in the adult population. [\\[8\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-8)\n\n[![](https:\/\/www.physio-pedia.com\/images\/thumb\/6\/6f\/Picture_.png\/300px-Picture_.png)](https:\/\/www.physio-pedia.com\/File:Picture_.png)\n\n[The age-specific point prevalence of low back pain in 2017, by gender.](https:\/\/atm.amegroups.com\/article\/view\/38037\/html)[\\[9\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-9)\n\nOne study that was carried out in 195 countries assessing the incidence, prevalence, and years lived with disability for 354 medical conditions found LBP to be the leading cause of worldwide productivity loss as measured in years, and the top cause of years lived with disability in 126 countries.[\\[6\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:3-6) In the United Kingdom (UK), it is estimated that LBP is responsible for 37% of all [chronic pain](https:\/\/www.physio-pedia.com\/Chronic_Pain_and_the_Brain \"Chronic Pain and the Brain\") in men and 44% in women and the total cost of LBP to the UK economy is reckoned to be over £12 billion per year. [\\[1\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1)\n\nRisk factors for LBP are age, sex, height, weight, sedentary lifestyle, depression, anxiety, insomnia, and smoking.[\\[10\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-10) Although muscle strain and imbalance, ligament sprain, and soft tissue damage account for almost all LBP, as it is [non-specific](https:\/\/www.physio-pedia.com\/Non_Specific_Low_Back_Pain), it often has no identifiable underlying condition or origin. [\\[11\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-11)\n\nOffice workers are usually required to sit for long hours working on a computer while spending most of their time in a sitting position. Approximately 34%- 51% of office workers experienced LBP in the preceding 12 months. Occupational groups exposed to '*poor postures'* while sitting for longer than half a day have a considerably increased risk of experiencing LBP. Subjects with LBP are likely to be in sustained postures and have large and infrequent spinal movements. Prolonged postural loading of the spine while sitting can reduce joint lubrication, fluid content of intervertebral discs, and increased stiffness. Additionally to this, prolonged muscle activation in static sitting may lead to localised muscle tension, muscle strains, muscle fatigue, and other soft-tissue damage, causing impairment of motor coordination and control as well as increased mechanical stress on ligaments and intervertebral discs.[\\[12\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-12)\n\nPrevalence of [walking in the United Kingdom](https:\/\/www.gov.uk\/government\/statistics\/walking-and-cycling-statistics-england-2020\/walking-and-cycling-statistics-england-2020):\n\n- People made an average of 236 walking trips and walked an average of 220 miles.\n- People on average have walked less than in 2019, following a fall in short walks.\n- People walked 7% farther in 2020 compared to 2019.\n\n- 67% of adults in England reported walking at least once a week.\n- 92% of local authorities had at least 60% of their adult population walking at least once a week.\n\nThe NHS provides a guide on ['walking for health'](https:\/\/www.nhs.uk\/live-well\/exercise\/running-and-aerobic-exercises\/walking-for-health\/), to help motivate the population and help them meet the recommended minimum moderate activity guidelines of 150 minutes.\n\n## Pedometer Driven Walking\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=4 \"Edit section: Pedometer Driven Walking\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=4 \"Edit section: Pedometer Driven Walking\")\\]\n[![](https:\/\/www.physio-pedia.com\/images\/f\/f9\/Pedometer._jp.jpg)](https:\/\/www.physio-pedia.com\/File:Pedometer._jp.jpg)\n\nExample of a pedometer\n\n[Pedometers](https:\/\/www.prevention.com\/fitness\/a20450112\/walking-tips-how-to-use-a-pedometer\/) are devices that work by counting the steps someone takes to estimate the distance they have traveled. [\\[13\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-13) Pedometers are usually worn at the hip (on the waistband of clothing) and in alignment with the patella although this may not be the case for all pedometers. There are also other ways of tracking steps - many people now have fitness trackers which are attached to the wrist and will also have the ability to count steps.\n\nInstructions will be included with pedometer devices, and as there are many [different types](https:\/\/www.prevention.com\/fitness\/a20450112\/walking-tips-how-to-use-a-pedometer\/) it is important to check these before usage to ensure that the pedometer is being used as accurately as possible. Some pedometers may also be more complex and do a little bit more than just counting steps such as showing calories burned, activity times, and memory logs.\n\nWhilst not a pedometer in the traditional sense, the [NHS](https:\/\/www.nhs.uk\/better-health\/get-active\/) (National Health Service) also has an application which is free to download called *'Active 10'* - this is designed to track walking and will indicate the total amount walked and how much of that was brisk walking. Within the app, there are also options to set goals, achieve milestones, and view progress over the weeks and months. So a pedometer is not the only option to keep a track of walking and daily activity - there are many more apps out there that will do the same thing\\!\n\nUsing an app as a pedometer or walking tracker does rely on the individual having a mobile phone and keeping it in their pocket to ensure it tracks all activity whereas a standard pedometer can be used by a wider number of people and may not be as complex.\n\n### Do Pedometers Increase Physical Activity?\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=5 \"Edit section: Do Pedometers Increase Physical Activity?\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=5 \"Edit section: Do Pedometers Increase Physical Activity?\")\\]\n[The NICE (National Institute for Health and Care Excellence) guidelines](https:\/\/www.nice.org.uk\/news\/article\/nice-publishes-updated-advice-on-treating-low-back-pain) on LBP and sciatica in over 16s - published in 2016 and last updated in 2020 - advises self-management and exercise as treatments. [\\[1\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1)A pedometer would be an easy way of giving someone a tool to help self-manage their activity levels, as long as this was an appropriate choice of exercise for the individual - those with LBP should be encouraged to continue with their regular activities as well. [\\[1\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1)\n\nA three-arm cluster, randomised control trial (RCT) conducted in 2016 with an eventual number of participants at 956 recruited from primary care settings, found that a pedometer-based walking intervention (regardless of whether there was nurse support) increased the step count and physical activity of generally inactive 45-75 year old at a 12 month follow up. [\\[14\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-14)A meta-analysis in 2009 of pedometer-based interventions for activity conducted in 2013 included 32 studies and found using pedometers to have a positive effect on physical activity and this was regardless of age or intervention length.[\\[15\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:13-15) The studies had varying interventions from keeping a daily log of steps, completing 10,000 steps, individualized goals, or a combination of strategies.[\\[15\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:13-15)\n\n### Do Pedometers Affect LBP?\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=6 \"Edit section: Do Pedometers Affect LBP?\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=6 \"Edit section: Do Pedometers Affect LBP?\")\\]\n#### Acute Low Back Pain (ALBP)\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=7 \"Edit section: Acute Low Back Pain (ALBP)\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=7 \"Edit section: Acute Low Back Pain (ALBP)\")\\]\nThere is arguably less research in relation to ALBP and the effects of using a pedometer. However, a study in 2015, focusing on those with ALBP of 48 hours or less looked at whether 'stay active' advice or 'adjusting activities to pain' had different effects. [\\[16\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:14-16) Participants were aged between 18 and 65 and all were provided with a pedometer to track daily steps with the instruction of wearing it at all times during waking hours, they found the pedometer an easily used intervention which increased physical activity, particularly in those with the advice to 'stay active'.[\\[16\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:14-16) This study shows that pedometers could have a useful place in treatment alongside other advice and management techniques for those with ALBP despite the study being over a short period of time, and the study size is relatively small.\n\n#### Chronic Low Back Pain (CLBP)\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=8 \"Edit section: Chronic Low Back Pain (CLBP)\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=8 \"Edit section: Chronic Low Back Pain (CLBP)\")\\]\nAs previously mentioned, [CLBP](https:\/\/www.physio-pedia.com\/Chronic_Low_Back_Pain \"Chronic Low Back Pain\") accounts for a significant amount of chronic pain in individuals of the UK, so interventions that aid in the treatment and management would be beneficial. A recent RCT published in 2021, looked at the effects of a pedometer-driven individualized walking plan compared to standardised care in increasing completion and adherence of physical activity in CLBP management.[\\[17\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:15-17)Whilst no significant difference was noted in disability or pain, there was an indication that using an individualised, guided pedometer program aided in adherence and participation of physical activity - although relevant measures such as step count were not taken from the standardised care group, so it is unclear if there were any increases in physical activity amongst them.[\\[17\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:15-17)\n\nA previous RCT from 2013, of an internet-based pedometer intervention, did find that in the short-term of 6 months back pain disability had decreased, but at 12 months there was no difference between the group with access to the internet support and the ones utilising the pedometer and standard management only.[\\[18\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-18)Again, this shows, that whilst pedometer-driven walking can have positive effects in physical activity and adherence, there may need to be further research to explore how positive outcomes can be gained in the long term.\n\nIt seems that pedometers can be a relatively cheap and accessibly form of intervention and management in individuals with LBP, and this can have greater positive impacts when included with support in one form or another.[\\[16\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:14-16)\n\n## Benefits of Walking on Low Back Pain\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=9 \"Edit section: Benefits of Walking on Low Back Pain\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=9 \"Edit section: Benefits of Walking on Low Back Pain\")\\]\n[![Walking dog.jpg](https:\/\/www.physio-pedia.com\/images\/thumb\/b\/b8\/Walking_dog.jpg\/300px-Walking_dog.jpg)](https:\/\/www.physio-pedia.com\/File:Walking_dog.jpg)\n\nThe lower back muscles play an important role in maintaining its stability and movement; two key aspects that are needed when walking. [\\[19\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:6-19) These [muscles](https:\/\/www.physio-pedia.com\/Muscle \"Muscle\") can become deconditioned in those with sedentary lifestyles, leading to weakness over time. This prolonged weakness can increase muscular fatigue, and injury, exaggerating the pain already being experienced. [\\[19\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:6-19) Reduced physical activity can also cause these muscles and the joints of the [lumbar spine](https:\/\/www.physio-pedia.com\/Lumbar_Anatomy \"Lumbar Anatomy\") to become stiff, which can increase the pressure on the lower back. [\\[20\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:7-20)\n\n[Walking has many positive impacts on the lower back](https:\/\/www.verywellfit.com\/walking-away-low-back-pain-3435479#toc-does-walking-really-prevent-low-back-pain), which can prevent or reduce these changes occurring in the following ways:\n\n1. Increased blood flow:\n   - Small blood vessels and capillaries in the lower back muscles can become constricted following decreased physical activity, [reducing the blood flow](https:\/\/www.spine-health.com\/blog\/2-reasons-why-walking-good-your-lower-back#vh_footnotes) to these muscles.\n   - Walking allows for more movement in these muscles, allowing these capillaries and blood vessels to open up again.\n   - This, in turn, increases the blood supply and nutrients to these muscles, improving muscular health and strength and aiding with the healing process. [\\[20\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:7-20)\n2. Stretch and contraction of muscles:\n   - The movement in the lower back during walking increases the stretch and contraction of the lower back muscles and those in the legs, buttocks, and core, allowing for more flexibility and mobility in this area.\n   - This flexibility [increases the overall range of motion](https:\/\/www.spine-health.com\/blog\/2-reasons-why-walking-good-your-lower-back#vh_footnotes) in the lower back, also improving the health and strength of the lower back muscles.\n\n[\\[21\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-21)\n\n## Treatment and Management\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=10 \"Edit section: Treatment and Management\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=10 \"Edit section: Treatment and Management\")\\]\n### Effect Of Walking On LBP\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=11 \"Edit section: Effect Of Walking On LBP\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=11 \"Edit section: Effect Of Walking On LBP\")\\]\nCurrent evidence supports the use of walking as a treatment option for LBP. A cross-sectional study from 2017 evaluating the relationship between walking and LBP, consisting of 5,982 adults, found that walking was associated with a reduced risk of LBP. [\\[22\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:9-22) The authors also found that the presence of LBP was proportionate to walking frequency, with those who walked more often having reduced LBP. These results are supported by those of a systematic review from 2019 evaluating the effects of walking on those with chronic LBP. [\\[23\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:10-23) Walking was found to be as effective as other non-pharmacological interventions on pain and disability in short-term (\\<3 months) and intermediate (3-12 months) follow-ups. These findings allowed for walking to be recommended for managing and treating LBP. [\\[23\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:10-23)\n\nThe effects of walking have been compared to the effects of exercise for LBP. A systematic review from 2019 comparing the two concluded that walking was as effective as exercise for improving pain, disability, quality of life, and fear-avoidance in those with chronic LBP. [\\[24\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:11-24) Much like the studies by Kim et al. [\\[22\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:9-22) and Sitthipornvorakul et al. [\\[23\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:10-23), Vanti et al. [\\[24\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:11-24) recommend the use of walking as a treatment and management option for LBP.\n\nInterestingly, a systematic review from 2022, found that people with LBP have altered gait patterns compared with healthy individuals. [\\[25\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:12-25) Those with LBP were found to walk slower, have reduced stride lengths, greater lumbar paraspinal activation, and reduced thorax\/pelvic coordination. [\\[25\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:12-25) However, the authors were unable to report if these changes were adaptive or maladaptive. Overall, these results indicate that gait re-education may be needed for those with LBP to gain the most benefits from walking.\n\nA systematic review in 2015 included seven randomised controlled trials involving 869 participants adults with chronic LBP. It compared walking to other non-pharmacological management methods such as usual care, specific strength exercises, medical exercise therapy, or supervised exercise classes. It suggested that walking is the same effective as other management methods while having a lower cost. [\\[26\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:18-26). It could be explained by its high accessibility, but does not require training, supervision, or specialised equipment. [\\[26\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:18-26)\n\nOther research supported that walking is as effective as conventional physiotherapy treatment such as lumbar stabilisation and muscle strengthening exercise. [\\[27\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:19-27)[\\[28\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:20-28) A randomised control trial included 48 participants comparing the effect of lumbar stabilisation exercise and walking exercise on LBP. It suggested both interventions significantly reduced LBP, and both interventions show similar results.[\\[28\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:20-28) Another randomised control trial compare strengthening exercise to a combined programme of strengthening exercise and walking exercise on chronic LBP. It suggested that both interventions were beneficial but combined exercise programme was more effective for reducing pain levels than the strength exercise. [\\[27\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:19-27)Another randomised control trial also supported 44 participants comparing conventional physiotherapy to a combination of conventional physiotherapy with walking exercise. It suggested that a combination of conventional physiotherapy with walking exercise is more effective to reduces pain and kinesiophobia, and improved function in patients with subacute and chronic non-specific LBP. [\\[29\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:21-29)\n\n### How to Use Walking as a Treatment for LBP\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=12 \"Edit section: How to Use Walking as a Treatment for LBP\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=12 \"Edit section: How to Use Walking as a Treatment for LBP\")\\]\n#### 1\\. Combine with conventional physiotherapy treatment\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=13 \"Edit section: 1. Combine with conventional physiotherapy treatment\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=13 \"Edit section: 1. Combine with conventional physiotherapy treatment\")\\]\nWalking is a low-cost intervention, and a combination of physiotherapy with walking is more effective than conventional physiotherapy alone. [\\[26\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:18-26)[\\[27\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:19-27)[\\[29\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:21-29) Walking exercise could be educated by physiotherapists alongside their exercise prescription. Recommendations support the use of exercise for at least 15 to 30 minutes most days for those with LBP. [\\[30\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-30) This can mean gradually building up walking distance and capacity to reduce the risk of injury and allow for the body to adapt to the changes.\n\n#### 2\\. Goal setting\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=14 \"Edit section: 2. Goal setting\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=14 \"Edit section: 2. Goal setting\")\\]\nThe use of a **pedometer** means that the patient is able to manage and keep track of their steps whilst walking. The patient might be advised to keep an **\"activity diary\"** which keeps track of a daily step count and the patient's step goal. This is achieved by calculating the patient's average step count in the first week of activity, and using this as a baseline when deciding a step goal for the second week. [\\[31\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:22-31) The use of an activity diary can also help establish the patients' baseline in the first week, which is important in informing their individual goals for rehabilitation. [\\[31\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:22-31)\n\nFor example, use pedometer\/tracking apps (like Active 10) to monitor and then set weekly targets (increase by a certain amount each week\/two weeks for example).\n\n#### 3\\. Postural Control\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=15 \"Edit section: 3. Postural Control\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=15 \"Edit section: 3. Postural Control\")\\]\nHaving the [correct walking posture](https:\/\/www.verywellfit.com\/how-to-walk-walking-posture-3432476) is important to allow for more comfortable walking, helping to reduce pain and discomfort. An optimal posture can be achieved using multiple strategies:\n\n1. Stand up straight:\n   - This can be achieved by making yourself as tall as possible, without leaning forwards or backward.\n   - Ensuring your chin is kept up and your eyes facing forwards allows for reduced strain on your neck and back.\n   - These together will allow for a better posture and improved balance. [\\[32\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-32)\n2. Keep shoulders back and relaxed:\n   - Relaxing your shoulders helps relieve tension and allows for a more neutral spine when walking.\n3. Engage core muscles and keep a neutral pelvis:\n   - engaging your core and keeping a neutral pelvis prevents arching of the spine and tilting of the pelvis, allowing for a more neutral spine and better posture. [\\[33\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-33)\n## Outcome measures\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=16 \"Edit section: Outcome measures\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=16 \"Edit section: Outcome measures\")\\]\nThere are a variety of outcome measures that might be used when advising walking as a management strategy for patients with LBP. These might look at:\n\n- Pain\n- Disability\n- Physical activity\n### Pain\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=17 \"Edit section: Pain\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=17 \"Edit section: Pain\")\\]\n#### Visual Analogue Scale (VAS)\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=18 \"Edit section: Visual Analogue Scale (VAS)\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=18 \"Edit section: Visual Analogue Scale (VAS)\")\\]\nThe **VAS ([Visual Analogue Scale](https:\/\/www.physio-pedia.com\/Visual_Analogue_Scale \"Visual Analogue Scale\"))** is one of the most common outcome measures for LBP. [\\[34\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-34)\n\nIt is an example of a subjective PROM (Patient Reported Outcome Measure), where the patient records their pain on a 100mm line- from \"no pain\" at the beginning to the \"worst pain imaginable\". Some types of VAS also use faces to represent pain from \"mild\", \"moderate\" to \"severe\", as shown below.\n\n[![](https:\/\/www.physio-pedia.com\/images\/thumb\/0\/02\/Visual_Analogue_Scale.jpg\/300px-Visual_Analogue_Scale.jpg)](https:\/\/www.physio-pedia.com\/File:Visual_Analogue_Scale.jpg)\n\nExamples of a VAS [\\[35\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-35)\n\nPrevious studies have found that the VAS is a \"reliable and valid\" outcome measure for use in a LBP population. [\\[36\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-36) It has also shown reliability in predicting disability due to LBP. [\\[37\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-37)\n\n![Logo](https:\/\/www.physio-pedia.com\/skins\/PhysiopediaSkin\/resources\/images\/plus-new-logo-white.png)\n\n## Introducing PAI - Your AI Clinical Partner in Physiotherapy\nEnhance your clinical reasoning, minimise paperwork and maximise patient interaction\n\n[Yes please\\!](https:\/\/members.physio-pedia.com\/physiopedia-ai-assistant\/?utm_source=physiopedia&utm_medium=content_advert&utm_campaign=standard_pai_ad_left_img)\n### Disability\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=19 \"Edit section: Disability\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=19 \"Edit section: Disability\")\\]\n#### Roland-Morris Disability Questionnaire (RMDQ)\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=20 \"Edit section: Roland-Morris Disability Questionnaire (RMDQ)\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=20 \"Edit section: Roland-Morris Disability Questionnaire (RMDQ)\")\\]\nThe **[Roland-Morris Disability questionnaire (RMDQ)](https:\/\/www.physio-pedia.com\/Roland%E2%80%90Morris_Disability_Questionnaire \"Roland‐Morris Disability Questionnaire\")** is a commonly used PROM, designed to assess a patient's disability in relation to their LBP. It is a 24-item questionnaire that looks at physical functions that the patient feels have been affected, and a higher score represents a higher level of disability due to LBP. [\\[38\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-38)\n\n[![](https:\/\/www.physio-pedia.com\/images\/thumb\/0\/0d\/RMDQ_picture.webp\/390px-RMDQ_picture.webp.png)](https:\/\/www.physio-pedia.com\/File:RMDQ_picture.webp)\n\nAn example of the RMDQ [\\[39\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-39)\n\nA study from 2020 found that the RMDQ had good test-retest reliability and internal consistency reliability in capturing the \"everyday functional impact of low back pain\". [\\[40\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-40)\n\n#### Oswestry Disability Index (ODI)\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=21 \"Edit section: Oswestry Disability Index (ODI)\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=21 \"Edit section: Oswestry Disability Index (ODI)\")\\]\nThe **[Oswestry Disability Index (ODI)](https:\/\/www.physio-pedia.com\/Oswestry_Disability_Index \"Oswestry Disability Index\")** is also commonly used to assess functional disability in patients with LBP. [\\[41\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-41) It consists of 10 items which are detailed below, as well as the interpretation of the scores.\n\n[![](https:\/\/www.physio-pedia.com\/images\/thumb\/4\/41\/ODI_QUESTIONS.jpg\/390px-ODI_QUESTIONS.jpg)](https:\/\/www.physio-pedia.com\/File:ODI_QUESTIONS.jpg)\n\nOswestry Disability Index (ODI) [\\[42\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-42)\n\n[![](https:\/\/www.physio-pedia.com\/images\/thumb\/8\/85\/ODI_interpretation.png\/300px-ODI_interpretation.png)](https:\/\/www.physio-pedia.com\/File:ODI_interpretation.png)\n\nInterpretation of ODI scores [\\[43\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-43)\n\nThe ODI has been found to be a \"valid and reliable scale suitable for measurement of disability for low back pain\", and in particular showing high test-retest reliability. [\\[44\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-44)\n\nA study looked at comparing the ODI and the RMDQ to each other. The study found that the ODI appeared to be better at detecting changes in patients with more severe lower back pain, whereas the RMDQ seemed to have an advantage when measuring patients who had more mild disability.[\\[45\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-45)\n\n### Physical activity\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=22 \"Edit section: Physical activity\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=22 \"Edit section: Physical activity\")\\]\n#### International Physical Activity Questionnaire (IPAQ)\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=23 \"Edit section: International Physical Activity Questionnaire (IPAQ)\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=23 \"Edit section: International Physical Activity Questionnaire (IPAQ)\")\\]\nThe International Physical Activity Questionnaire (IPAQ) is formed of two different versions including the IPAQ short-form and the IPAQ long version. Both versions require the patient to recall their physical activity levels in the **past 7 days.** Based on these scores, they are placed in one of three categories: low activity levels, moderate activity levels, and high activity levels. [\\[46\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-46)\n\nThe **[IPAQ short-form](https:\/\/evaluationframework.sportengland.org\/media\/1084\/2015-ipaq-sf.pdf)** consists of 4 categories where the patient reports how much they participated in the following activities in the past 7 days:\n\n- Moderate activity\n- Vigorous activity\n- Time spent walking\n- Time spent sitting\n\nThe IPAQ short-form may be more beneficial for use in a clinical setting due to the shorter\/more accessible nature of the questionnaire for patients. [\\[47\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:2-47)\n\nThe **[IPAQ long version](https:\/\/www.physio-pedia.com\/images\/6\/6e\/International_Physical_Activity_Questionaire)** assesses physical activity across 5 domains:\n\n1. Job-related physical activity\n2. Transportation physical activity\n3. Housework, house maintenance, and caring for family\n4. Recreation, sport, and leisure time\n5. Time spent walking\n\nThe IPAQ long version is typically used in research studies or may be used if a more detailed picture of a patient's physical activity levels is preferred. [\\[47\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:2-47)\n\nOverall, the [IPAQ](https:\/\/www.physio-pedia.com\/images\/6\/6e\/International_Physical_Activity_Questionaire) has been subject to extensive reliability and validity testing across 12 different countries (14 sites) from 2000 as an outcome measure for physical activity.\n\n## Suggestions for Future Clinical Research\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=24 \"Edit section: Suggestions for Future Clinical Research\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=24 \"Edit section: Suggestions for Future Clinical Research\")\\]\n- Based on the current literature, walking has been shown to be an effective management strategy for patients with LBP. However, more high-quality RCT’s need to be carried out using a  **variety of outcome measures,** including physical activity, to further investigate walking as an effective management strategy for LBP.\n\n- In order to strengthen the current evidence around this topic, further research could be carried out on how to ensure the **long term** **effects** of pedometer-based intervention. It would also be valuable to investigate whether added interventions might be necessary in aiding supportive positive outcomes long-term.\n- The current NICE guidelines for LBP and sciatica were published in 2016 and updated in 2020 for pharmacological interventions. However, the advice for “non-pharmacological interventions” last had an evidence review in **2016\\.** Therefore, it may be beneficial for a reassessment based on new evidence, in which guidelines around walking could be evaluated.\n\nRelated articles\n\n[Inactivity and Low Back Pain - Physiopedia Introduction According to NICE Guideline,p ublished in30 November 2016 and updated in December 2020 , the lower back can be defined as the area between the 12th ribs and the buttock creases.\\[1\\] \"Non-specific\" low back pain is defined as low back pain not attributable to a recognisable, known specific pathology (e.g. infection, tumour, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome).\\[2\\] The time frame of low back pain classification:\\[3\\] Acute low back pain – symptoms less than 6 weeks Sub-acute low back pain – symptoms last between 7-12 weeks Chronic low back pain – symptoms last more than 12 weeks \\[4\\] You can find guidelines regarding low back pain here. Physical Activity and Inactivity\\[edit \\| edit source\\] “Physical activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure.”\\[5\\] Physical activity includes activities of daily living, such as walking, housework, gardening, and work-related activities.\\[6\\] When an individual does not meet the recommended level of physical activity, he or she will be classified as physically inactive. The 2013 NICE Guideline recommendations (UK Chief Medical Officers’ physical activity recommendations) for physical activity state the following:\\[6\\] All adults aged 19 years and over should aim to be active daily Over one week, daily activity should add up to at least 150 minutes (2.5 hours) of moderate intensity physical activity in bouts of 10 minutes or more Alternatively, comparable benefits can be achieved through 75 minutes of vigorous intensity activity spread across the week or combinations of moderate and vigorous intensity activities All adults should also undertake physical activity to improve muscle strength on at least 2 days per week All adults should minimise the amount of time spent being sedentary (sitting) for extended periods Older adults (65 years and over) who are at risk of falls should incorporate physical activity to improve balance and coordination at least 2 days per week Individual physical and mental capabilities should be considered when interpreting the guidelines, but the key message is that some activity is better than no activity The World Health Organisation (WHO) has classified physical inactivity into two levels. Level 1 exposure (inactive): an individual does very little or no physical activity at home, work, for transport or in his\/her private time Level 2 exposure (insufficiently active): an individual does physical activity less than 150 minutes of moderate-intensity or 60 minutes of vigorous-intensity physical activity in all activities of daily living.\\[7\\] The current levels of physical inactivity are partly due to insufficient participation in physical activity during leisure time and an increase in sedentary behaviour during occupational and domestic activities.\\[8\\] Sedentary Behaviour\\[edit \\| edit source\\] National guidelines classify people as sedentary when an individual does less than 30 minutes of moderate activity on all or most days of the week.\\[9\\] Sedentary behaviour describes activities that do not increase energy expenditure significantly above the resting level. It includes activities such as sleeping, lying, watching television ,and other types of screen-based entertainment. However, light physical activity is often mistaken as sedentary behaviour, such as slow walking, sitting, writing, and cooking, but these do require energy expenditure above the resting level.\\[10\\] Low Back Pain- Statistics\\[edit \\| edit source\\] One-third of the United Kingdom adult population is affected by low back pain each year 20% (1 in 15 of the population) of people will consult a GP about their low back pain\\[1\\] In Europe, the lifetime prevalence of low back pain can be as high as 84% After the first experience of low back pain, 44-78% of people suffer for relapse of pain again 26-37% of people will have relapses of work absence after an initial episode of low back pain Evidence has shown that the prevalence of chronic non-specific low back pain is around 23%, and 11-12% of the population is disabled by this condition\\[11\\] 85% of cases are classified as non-specific low back pain as a diagnosis cannot be made by radiological methods\\[12\\] Regarding IASP (International Association for Study of Pain): \"Low back pain is a common global problem. The point prevalence of LBP in 2017 was estimated to be about 7.5% of the global population, or around 577.0 million people \\[2\\]. LBP has been the leading cause of years lived with disability (YLDs) since 1990 \\[2\\] and remains a significant global public health concern. 85-95% of people presenting to primary care providers do not have a specific identifiable pathoanatomical origin for their pain \\[3\\]. The proportion of people presenting to primary care with a specific identifiable cause of LBP is estimated to be 0-7-4.5% with osteoporotic vertebral fractures, 5% with inflammatory spondyloarthropathies4, 0.0-0.7% with malignancy, and 0.01% with infections. The global burden of disability associated with LBP has been increasing since 1990. Disability associated with LBP increased in all age groups between 1990 and 2019 and was greatest in the 50-54 age group in 2019. Approximately 70% of years lost through disability were in working-aged people (20-65 years) There have been increases in both the number of people living with LBP and the prevalence of LBP in all age groups from 1990 to 2017. Although the prevalence of LBP increases with increasing age until 80-89 years, the greatest number of people with LBP globally are currently in the 50-54 year age group. The overall increase in the burden of LBP is likely to be driven by ageing and an increasing population, however, there may be other contributing factors .\" Physical Inactivity\\[edit \\| edit source\\] Around the world, one in five adults is considered physically inactive In developed countries, physical inactivity was found to be more prevalent in women and the elderly Female physical inactivity was higher (21.4%) than male (18.9%)\\[13\\] Approximately 60% of male adults, 72% of female adults, 68% of boys, and 76% of girls aged 2-15 do not meet the UK Chief Medical Officers’ physical activity recommendations\\[14\\] Physical inactivity has been reported as the fourth leading risk factor for global mortality (6% of deaths worldwide)\\[15\\] Around 3.2 million deaths each year are related to insufficient physical activity\\[16\\] Health Complications\\[edit \\| edit source\\] Physical inactivity and sedentary behaviour can contribute to the following:\\[16\\] Hypertension Cardiovascular heart disease Stroke Diabetes Breast and colon cancer Depression Anxiety Risk of falls Obesity Osteoporosis Lipid disorders Low back pain Physical Activity- outcome measures\\[edit \\| edit source\\] The outcome indicator should be chosen according to how well it measures the objectives of the study. Other important factors in choosing an outcome measure are the level of data required, the characteristics of the individual, group or population, time frame of interest, and the available time and resources.\\[17\\] Physical activity can be classified as a combination of frequency, intensity, and duration. Any type of activity can be different in terms of the three different aforementioned elements. A better understanding of what element or activity that a study is focused on, the easier it is to determine what outcome measure is most appropriate.\\[18\\] Measurement of physical activity can be challenging. The outcome measures for physical activity are generally of two types: objective measures (e.g. accelerometers, pedometers, heart-rate monitors, armbands ) subjective measures (e.gself-report questionnaires, self- report Activity Diaries\/Logs, Direct Observation). Each has a different degree of validity (i.e. the extent to which an instrument genuinely records what it is intended to measure),\\[19\\] reliability (i.e. how consistently an instrument or tool will measure something on two or more separate occasions),\\[20\\] feasibility and practicality. However, there is no ‘gold standard’ for assessing physical activity in public health settings.\\[21\\]\\[22\\]\\[23\\] Below are the options for measuring physical activity suggested in the Standard Evaluation Framework for physical activity interventions, published by the National Obesity Observatory. The measure of a specific type of physical activity Measure of the total physical activity Proportion achieving recommended physical activity levels Public Health England published Standard Evaluation Framework for Weight Management Interventions in February 2018. Self-report approaches are the most frequently used method for measuring physical activity in a public setting due to its cost effectiveness compared to other outcome measures. However, their reliance on recalling activity can be problematic, especially for children and young peopSelf-reportport of physical activity is subject to a number of types of bias, such as recall bias, lack of compliancedesirability desirability’ bias.\\[24\\] Below is a short list of selected questionnaires for physical activity and diet:\\[25\\]\\[26\\] Children and Young People Adults The Physical Activity Questionnaire for Older Children\/Adolescents (PAQC\/PAQ-A) Youth Risk Behaviour Surveillance Survey (YRBSS) The Teen Health Survey Stanford 7-day recall (7-DR) International Physical Activity Questionnaire Long version (IPAQ-Long) New Zealand Physical Activity Questionnaire (Short Form) (NZPAQ-Short) 7-day Physical Activity Diary A systematic review by Falck et al. 2015 evaluated the measurement tools used in interventions to increase physical activity among older adults, including both objective and subjective measures. 44 studies were included, with 32 of them using self-report measures, 9 using objective measures, and 3 using both. Among all the measures, only 57% of them had population-specific reliability and 66% had population-specific validity. A majority of the studies used self-reported measures, even though many had little evidence of validity and reliability. The researchers of the systematic review suggested that future researchers should use valid and reliable measures of physical activity with well-established evidence of psychometric properties, for instance, hip accelerometers and the Community Health Activities Model Program for Seniors Physical Activity Questionnaire for older adults. With the advance in modern technology, access to technology for measuring physical activity, such as accelerometers and pedometers, is easier than ever, so future researchers sh ld take the opportunity to improve the quality of their studies by using better measurement tools. \\[27\\] On the other hand, it is important to note that most of the questionnaires were not developed for use in individual or group iterventions, but for population surveillance. In some cases, the tools may not have been sensitive enough to measure the outcome. Furthermore, none of the tools can adequately deta ect change in physical activity over time, but capture more of a snapshot of a particular period of time.\\[28\\] For Low Back Pain\\[edit \\| edit source\\] Visual Analogue Scale (VAS) Numerical Pain Rating Scale (NPRS) Roland–Morris Disability Questionnaire (RMDQ) Oswestry disability index (ODI) Pain Self-Efficacy Questionnaire (PSEQ) Patient Specific Functional Scale (PSFS)\\[29\\] Other Outcome Measures\\[edit \\| edit source\\] Body Mass Index (BMI), physiological measures, and quality of life are frequently used as secondary outcome measures for physical activity. However, these outcome measures should only be used if they are relevant to the aims ofand the study other researcherinterestsest. Cycle of Physical Inactivity Causing Low Back Pain\\[edit \\| edit source\\] \\[30\\] Bone Strength and Disc\\[edit \\| edit source\\] Bone health is also likely to be affected in an inactive population. According to Wolff’s Law, if the loading on a bone decreases, the bone will become less dense and weaker due to the lack of the stimulus required for continued remodeling and increased resorption from osteoclasts.\\[31\\] Physical activity can influence bone mass by causing compressive or bending loads on bone. The bone formation will then be the resultant response from the strain\/temporary deformation which will trigger primary and secondary responses in bone.\\[32\\] As such, being physically inactive may put one more at risk of having a low bone mineral density and consequently developing osteoporosis. However, current evidence still lacks high-quality studies to confirm the inverse relationship between back pain and bone health.\\[33\\]\\[34\\] A 2015 study demonstrated a 'dose-response relationship' between physical inactivity, including narrow intervertebral disc height. Intervertebral disc narrowing is a feature of degenerative disc disease, suggested by some to be the single most important structural risk factor for low back pain.\\[35\\] Musculoskeletal\\[edit \\| edit source\\] Evidence suggests that in response to physical inactivity, skeletal muscles go through a process called adaptive reductive remodeling.\\[32\\] This results in a loss of muscle mass (atrophy) and changes in muscle composition. Muscle atrophy is characterized by a general reduction in muscle cfibresectional fiber area as well as a reduction in the overall number of mfibresfibers,\\[36\\] leading to a decrease in muscle strength. Studies have shown that paraspinal muscles atrophy and increase in fat content are associated with low back pain as the result of physical inactivity.\\[37\\]\\[35\\] Metabolism\\[edit \\| edit source\\] Chronic LBP patients who are deconditioned, have their level of activity affected but also other parts of their body . For instance, metabolic factors including carbohydrate and lipid metabolism will become less efficient and effective than healthy non-chronic LBP individuals.\\[32\\] As a reduced physical activity level will eventually lead to weight gain and a change in body composition, people with LBP are reported to have a higher body fat percentage compared to age- and gender-matched individuals.\\[38\\] Obesity has been shown to have the strongest association with seeking care for low back pain.\\[39\\] Factors Affecting Adults Participation in Physical Activity\\[edit \\| edit source\\] Occupation\\[edit \\| edit source\\] A person with a job that requires a relatively high demand for physical activity can be sedentary in his leisure time. However, although the physical activity guideline is met he\/she may still be considered sedentary but physically active. On the other hand, a person with a sedentary job can be very active in his\/her leisure time, and his\/her physical activity may meet thuideline and he will not be classified as physically inactive. The type of occupation could affect the amount of physical activity, but it doesn’t necessarily have a direct influence on the physical activity one does during leisure time. The above figure demonstrates time trends for the prevalence of leisure time physical activity (LTPA) and work-related physical activity (WRPA). Values are from the Spanish National Health Interview Survey and are expressed as percentages. Type of occupation\\[edit \\| edit source\\] International research indicates that blue-collar employees typically exhibit lower rates of leisure-time physical activity. While “lack of time” and “work demands” are commonly reported barriers to activity, a secondary analysis of cross-sectional data from the Australian Health Survey found out among the three categories of occupations (professional, white-collar, and blue-collar), individuals in blue-collar occupations were approximately 50% more likely to be classified as insufficiently active.\\[40\\] Another systematic review found that white-collar\/professionals demonstrated the highest leisure-time physical activity compared to blue-collar workers and concluded that there is convincing evidence that those employed in occupations demanding long work hours and low occupational physical activity are at risk of inactivity.\\[41\\] From both studies, they showed that there is an association between physical inactivity and type of occupation. Job Position, Job Stres,s and PsychologicMany factors can\\[edit \\| edit source\\] There are many factors that can affect a person’s physical activity. A cross-sectional study by Martins and Lopes (2013) investigated the association of rank (position of the job in an office setting), job stress, and psychological distress with physical activity in a military setting. The results showed that lower rank (‘high effort and low reward’) was associated with more occupational physical activity, more job stress, and with less physical activity in sports\/physical exercise in leisure, and that psychological distress was associated with less physical activity in sports\/exercise in leisure.\\[42\\] Environment\\[edit \\| edit source\\] The physical environment has a consistent association with physical activity bbehavior One review showed that accessibility, opportunities, and aesthetic attributes had significant associations with physical activity. Weather and safety showed less-strong relationships.\\[43\\] However, it is hard to isolate one factor from others, other variables affecting physical activity behaviour, and whether the changes are caused by the factor that the researcher is interested in is unknown. A better research model and measurement strategies is needed for future research. Other Factors\\[edit \\| edit source\\] Personal factors enjoyment of exercise expectation of benefits intention to exercise self-efficacy self-motivation social support from friends\/peers\/spouse\/family lack of time Race\/ethnicity Social class etc.\\[44\\] Evidence For\\[edit \\| edit source\\] A Dutch cross-sectional study from 2009\\[45\\] investigated the U-shaped relationship between physical activity and low back pain. The study concluded that both extremes of physical activity, excess activity or insufficient activity, associated with a high risk of LBP. An increased prevalence in LBP was also found in inactive participants with sedentary behavior. In addition, there is a potential gender-related risk for LBP in inactivity because the result is more significant in women compared to men. Another cross-sectional study from 2015\\[35\\] explored the association between physical inactivity and intervertebral disc height, spinal muscles, fat content and low back pain, and disability. Results concluded that participants with lower activity levels had higher BMI, narrower intervertethe bral disc height, higher fat content of multifidus,and increased risk of high-intensity pain\/disability ratio after adjustment for age, gender and BMI. Further details are explained in the following table. Evidence Against\\[edit \\| edit source\\] A systematic review written in 2011 reviewed 7 studies to look at if patients with chronic low back pain have an altered level and\/or pattern of physical activity compared to healthy individuals. The gathered data revealed no significant difference in the overall activity level of adults (18-65 y\/o) or adolescents (\\<18y\/o) with chronic low back pain; however, there is evidence that older adults (\\>65 y\/o) with chronic low back pain are less active than controls. They concluded that there is no conclusive evidence that patients with chronic low back pain are less active than healthy individuals and there is a lack of studies in this area.\\[46\\] \\[47\\] Limitations\\[edit \\| edit source\\] The current literature looking at physical inactivity causing LBP are mainly cross-sectional studies. However, physical activity is continuous and patterns could change. Therefore, future longitudinal studies will help to better identify this cause and effect relationship.\\[48\\] Furthermore, pain is complex and difficult to measure due to its subjective nature and it being a multidimensional experience. There is no external reference or gold standard.\\[49\\] Physical activity is generally measured using self-reported questionnaires, which can lead to overestimation or underestimation. People generally tend to overestimate physical activity and underestimate sedentary behavior\\[50\\], which reflects the reliability and validity of questionnaires. A more sensitive alternative to questionnaires would be to use objective instruments such as pedometers, accelerometers, or heart rate monitors. Interviews\\[edit \\| edit source\\] An interview with Grahame Pope, the Head of Physiothe therapy Education at University of Nottingham An interview with Eric Bandoo, a band 6 Physiotherapist at Nottingham Citycare trust](https:\/\/www.physio-pedia.com\/Inactivity_and_Low_Back_Pain?utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal)   [Pain Neuroscience Education (PNE) for Low Back Pain - Physiopedia Introduction Pain Education is an intervention designed to help individuals experiencing chronic pain understand what is happening within their own body's, it aims to reconceptualise pain as a protective output of the brain rather than it being an accurate measure of tissue damage.\\[1\\] The way it is defined varies dependent on literature but the principles remain the same . \\[2\\]\\[3\\]\\[4\\] Pain education is consistently recommended as an intervention for musculoskeletalconditions as it can be used for both prevention and treatment. \\[4\\]\\[5\\] It provides a foundation for better self-informed treatment choices as well as self-monitoring & self-management activities. \\[4\\] Education Intervention Terms:\\[edit \\| edit source\\] \\[4\\] Key messages in Pain Education:\\[edit \\| edit source\\] Acknowledgement & acceptance of persistent pain Reframing of unhelpful beliefs about LBP Building a support team Pacing (behavioural therapy technique) Learning to prioritise and plan days Setting Goals\/Action Plans Being patient with one-self Learning relaxation skills Incorporating stretching & exercise Having back up plans for set backs \\[2\\]\\[3\\]\\[6\\] A systematic review and meta-analysis by Traeger et al. \\[2\\] provides evidence that all these concepts applied in patient education can reassure patients with chronic pain and such effects are maintained up to 12 months. Pain Neuroscience Education\\[edit \\| edit source\\] Pain neuroscience education (PNE) consists of educational sessions describing the neurobiology and neurophysiology of chronic pain and processing with particular focus on the role of the Central Nervous System (CNS) on chronic pain and deemphasising anatomical issues.\\[7\\] It promotes patient understanding of chronic pain and changes maladaptive thoughts and cognitions, for instance, pain catastrophising. \\[7\\] Through addressing these neurophysiological and neurobiological contributors of pain, PNE has been found to have a short and long-term positive effects on multiple factors, such as pain, disability, catastrophising, overall physical performance and demand on healthcare systems.\\[8\\] The key messages found within general pain education are also reinforced in pain neuroscience although the mode of delivery can vary. For key concepts of PNE - see here Pain Neuroscience Education delivery strategies:\\[edit \\| edit source\\] Online module format Single vs Multiple sessions One-to-One vs Group sessions Written vs Online Videos Metaphors Stories Videos \\[9\\] Low Back Pain\\[edit \\| edit source\\] Low Back Pain (LBP) has several definitions dependent on the source but majority of literature defines it as \"pain, muscle tension or stiffness localised below the costal margin and above the inferior gluteal folds typically, accompanied with or without pain and or neurological symptoms in one or both lower limbs\". \\[10\\] \\[11\\] For the majority of individuals with LBP, it is not possible to identify a specific nociceptive cause and only a small proportion have well understood pathological causes \\[11\\] i.e. vertebral fracture, malignancy etc, hence why it is commonly termed as 'non-specific'. It can be categorised in 3 subtypes: acute , sub-acute and chronic. Key concepts, anatomical structures and possible pathological causes - see here LBP is ranked as the highest leading cause of disability globally. \\[3\\]\\[11\\] 50-80% of adults experience LBP, it is a common disorder which impacts 2 billion people globally \\[12\\]\\[13\\] It is uncommon within the 1st decade of an individuals life but increases steeply during teenage years with around 40% adolescents in high, middle and low income countries reporting of LBP. \\[11\\] Studies have shown that the 1-year incidence of people experiencing LBP ranges from 1.5%-36% and 6.3%-15.4%. \\[14\\] Patients who experience acute LBP are found to have a high prognosis, however studies have found recurrence is common for 33% of individuals within 12 months and within a population of approximately 20-40%, LBP will become persistent and disabling (chronic). \\[14\\] In 2015, the global prevalence of activity -limiting LBP was 7.3%, 540 million people were affected at any one time.\\[11\\] Some studies suggest that there are predisposing factors such as age, gender, weight, occupation and particularly, occupational-related musculoskeletal disorder\/ repetitive strain injury. \\[11\\] \\[14\\] Occupational-induced LBP is estimated to cause 21.7 million Disability Adjusted Life Years (DALYs). \\[15\\] LBP is characterised by a range of biophysical, psychological and social dimensions. Individuals with LBP, particularly chronic, are known to experience poor sleep quality and health perception, worsened quality of life (QoL) and depressive symptoms. \\[12\\] Several studies and researchers have found that LBP results in fear-avoidance (i.e. kinesiophobia), \\[8\\] anxiety, catastrophising and as well as it being the biggest reason for leave and absenteeism at work, \\[13\\] \\[14\\] it also causes an overuse \/ strain of the healthcare systems, with approximately 68% of individuals visiting a physician over a year. \\[13\\] Biopsychosocial Theory\\[edit \\| edit source\\] The biopsychosocial theory and model is one of the fundamental theories within pain neuroscience education\\[9\\] and it as a intervention for chronic musculoskeletal disorders. It has been particularly vital in the transitioning and evolving beliefs of LBP. Previously, LBP was mainly understood from a biomedical approach which meant that clinicians held biomedically oriented beliefs and offered advice that promoted less activity and more time off work. \\[16\\] Research has since shown that such advice was interpreted by patients as indicating activity to be dangerous hence leading into factors such as fear-avoidance, catastrophising etc. \\[12\\] Through several research, over the past 15-20 years, clinicians have been encouraged to shift management of chronic musculoskeletal pain from a biomedical\/biomechanical approach to the biopsychosocial, \\[12\\] as psychosocial factors play an important role within individuals who experience chronic pain and has an impact on their function and QoL. All the psychological attributes associated with LBP such as fear-avoidance, catastrophic thinking and familial & social stress (stress-pain cycle) can increase the risk of physical disability which manifests as reduced functional capacity, avoidance of usual activities including work as well as impaired societal and recreational participation. \\[10\\] A systematic review in 2021 by Siddall et al.\\[8\\] concluded that there was a major barrier to exercise in patients with chronic pain due to kinesiophobia. Patients with low knowledge on the neurophysiology display high kinesiophobia and ultimately, it has been found that high levels of kinesiophobia is associated with reduced exercise adherence and an increase in pain & disability, \\[8\\] hence why pain neuroscience education is useful, as it aims to increase an understanding of the biopsychosocial nature of pain and the adaptability of the body. \\[9\\] Related Evidence\\[edit \\| edit source\\] Clinician perspective\\[edit \\| edit source\\] A clinician’s perspective to a treatment would concern assessing the relevant outcome measure to determine the effectiveness from that treatment \/ intervention. In the context of PNE and LBP, the consensus amongst research is that pain, and disability are dominant outcome measures used and can be applied through different questionnaires to evaluate these outcomes. Other outcome measures used in research include psychosocial elements to them such as quality of life, self-efficacy, catastrophising and kinesiophobia. Outcome measures to evaluate the use of PNE on LBP\\[edit \\| edit source\\] Pain – VAS \/ NRS Disability – ODI \/ RMDQ QOL - EQ-5D Kinesiophobia – Tampa scale Catastrophising - pain catastrophizing scale PNE\\[edit \\| edit source\\] Systematic review evidence that investigated the effect PNE has on musculoskeletal and LBP in patients included studies that evaluated the effect of PNE as a stand alone intervention. 2 studies from Wood and Hendrick \\[17\\] and 5 studies from Louw et al.\\[18\\] contained information regarding PNE's individual effect. Results showed that no study was able significantly decrease pain and there was low to moderate evidence for improving disability in the short-term or at all in regards to given outcome measures in the reviews. \\[17\\] \\[18\\] Whilst PNE's effectiveness on physical attributes are not as applicable as a stand-alone intervention, PNE's stand-alone effect on psychosocial components shows promising evidence to support its use. Evidence suggests that PNE can improve other elements that can facilitate function such as kinesiophobia and illness perceptions. \\[19\\] However, limited evidence, although favourable, can't solely justify the individual application of PNE therefore future research needs to investigate this further. PNE and Physiotherapy\\[edit \\| edit source\\] Clinicians will often incorporate the application of PNE in alignment with usual physiotherapy care (manual therapy\/exercise prescription) as to utilise a multi-modal approach when treating chronic back pain. \\[20\\] There is compelling evidence to support the use of PNE along with physiotherapy interventions to have short- term improvements on pain. Systematic review & meta analysis evidence looking at PNE and physiotherapy in the treatment of chronic low back pain found that there was low to moderate evidence in the short-term for pain. \\[8\\]\\[17\\] \\[21\\] Additional evidence also highlights its moderate effects on improving disability. \\[18\\]\\[22\\] A dose-effect relationship has also been implied for single PNE sessions, i.e. \\> 60 minutes, 4 to 8 sessions, intervention duration for 7 to 12 weeks, and following a group-based approach.\\[21\\] Information in the mentioned evidence does not specify what type of physiotherapy intervention is superior to one another. However, emerging research has found propitious evidence to support PNE alongside motor control training (MCT) as its suggested to deliver more effective results in improving pain and disability compared to current best-evidence physiotherapy care. \\[23\\]\\[24\\] MCT has also shown better results compared to core stability exercise, \\[25\\], although this result was exclusive to women due to the population studied thus limiting its validity. With limited evidence, it is hard to distinguish which intervention format is more effective to combine with PNE and therefore warrants the need for further research to determine clear differences in the interventions. Updating current systematic evidence could help establish clearer findings. PNE and physiotherapy effect on psychological aspects of patients showed potential improvements to kinesiophobia and catstrophisation but improvements were negligible failing to demonstrated clinically meaningful changes. \\[17\\] Type of physiotherapy care used with PNE\\[edit \\| edit source\\] Manual therapy Exercise prescription Aquatic therapy Paced\/Graded exposure Acupuncture\/dry needling Motor control training Patient perspective\\[edit \\| edit source\\] A patient’s treatment perspective involves two main components: the patient’s views about their health (e.g. what the condition is, what its causes are and how serious it is to the patient) and the patient’s values (e.g. what will help them most and how this can be achieved). Patients values and beliefs\\[edit \\| edit source\\] Minimal research investigates the patient’s values in learning about their pain. However, a mixed-methods survey found that patients believed PNE was necessary for their improvement of persistent pain. \\[26\\] PNE as an intervention provides a coherent biological explanation for how emotions such as stress can initiate a hormonal response which can sensitise neural processes associated with pain.\\[18\\] Pain reconceptualisation helps manage stress and anxiety, limiting the pain induced by these emotions. Although there’s limited research in this area, the mixed-methods review provides contextualised insight into qualitative data on the research question, providing a foundation for refining PNE to focus on pain concepts deemed most valuable to people with pain and use patient-centred language to best communicate the concepts. A common belief that follows pain is the concept that pain means damage; therefore, learning that pain does not indicate bodily or tissue damage can help manage patients’ pain. \\[26\\] These findings are consistent with the fear-avoidance model, which describes how individuals may develop musculoskeletal pain due to avoidant behaviour based on fear. \\[27\\] When a patient is gradually exposed to fear situations, understanding fear-avoidance concept leads to less fear of injury and less avoidance of movement and behaviours. If a patient engages, pain may become less threatening, changing their priority from pain control to valued life goals, e.g., decreasing disability and kinesiophobia, through using positive connotations such as \"understanding that even though it hurts, it is not a sign of damage\". \\[18\\]\\[28\\] Education\\[edit \\| edit source\\] Teaching\\[edit \\| edit source\\] There is limited research which evaluates the most effective use of PNE. Typically, PNE sessions are delivered in fifteen-to-thirty-minute sessions once or twice a week for four to six weeks. \\[29\\] They aim to decrease inappropriate beliefs and maladaptive behaviours associated with their chronic pain experiences. Teaching is most effective if taught by an experienced clinician. \\[30\\] Delivery\\[edit \\| edit source\\] Patients should receive individualised instructions and sessions are primarily delivered as verbal one-to-one sessions; however, new research suggests that it is beneficial to promote and conduct PNE in a group-based setting. \\[31\\]. Group strategy can be a powerful tool in encouraging values such as group feelings, improving self-esteem, and increasing adherence to the individual strategy. For example, a consequence of chronic pain may be kinesiophobia (the fear of movement). Romm et al. \\[31\\] concluded that group-based interventions significantly affect kinesiophobia through biopsychosocial interventions and learning theories such as observational learning. Patient-Clinician Relationship\\[edit \\| edit source\\] To maximise the effectiveness of PNE, it is essential to build rapport with the patient. Research has shown that the patient-clinician relationship has a statistically significant effect on healthcare outcomes. \\[32\\]. Within the PNE intervention, the patient-clinician relationship is vital as the patient needs to trust and comply with the instructions given by the practitioner to aid their recovery. Future research\\[edit \\| edit source\\] There are still areas within PNE that need to be further researched. One shortcoming is the heterogeneity of studies as age range, gender, and education don’t tend to be considered. Bilterys et al. \\[33\\] found no clinically meaningful differences in the effectiveness of PNE between educational levels. However, this has minimal research and would be beneficial to further understand patient factors affecting PNE. Despite the evidence suggesting the positive benefits of PNE, the educational process and specific parameters that are key to improving patient outcomes are still unknown; furthermore, the therapist-patient interaction warrants further exploration when using educational components in the management of chronic pain. \\[34\\] Zimney et al. \\[34\\]propose behaviour change, optimising the learning environment and using an individualised multimodal approach when using the PNE programmes in the management of chronic pain. Clinical application of PNE\\[edit \\| edit source\\] One aspect of PNE within the literature with little controversy is that PNE produces the most favourable outcomes when used in conjunction with more 'traditional' physiotherapy treatments. Utilising the current literature, in particular a study from Louw et al., \\[35\\] we have outlined a strategy which clinicians can utilise to incorporate PNE into their practice. First session\\[edit \\| edit source\\] Within the first session, a comprehensive assessment of the patient will be completed. This is like a 'traditional physiotherapy assessment' as it gathers both subjective and objective information which the clinician can utilise to inform their diagnosis and treatment. We propose the first session should be split into 4 sections which should total to around 1 hour: Conversation\/interview (~25-30mins): Initially clinicians should have a conversation with the patient where they predominantly listen to the patient, gathering information about their experiences, suffering and beliefs. This part should not be rushed, and adequate time is needed for the patient to tell their own story. Within this time the clinician can take note of any issues\/beliefs which the patient mentions which may need to be addressed in later PNE sessions. Physical examination (~10 mins): It is important that significant pathologies are ruled out to ensure that there is no underlying sinister pathology. Physical examination will also give us objective markers that we can utilise to track the progress of individuals to see if treatment is effective. The results from this examination should be conveyed to the patient, with emphasis on the use of clinician language to avoid terms like “wear and tear” which have negative connotations. Introduction to PNE (~10-15mins): Depending on the time availability of the clinician following a thorough assessment, PNE can then be briefly introduced to the patient. A good way to start the conversation is asking “Has anyone explained to you why you are still experiencing pain?”. If the patient is interested in learning more this is when a brief metaphor can be used to start to explain the hyper sensitive nervous system which is contributing to their pain. A common metaphor used is an oversensitive alarm clock (described below), however there is a number of metaphors used within pain education and research has found that no individual story or metaphor is superior to another. \\[36\\] 'Tame the beast' by Lorimer Moseley is another popular metaphor which can be utilised by patients, one benefit to this metaphor is that it has a patient centred video which clinicians can signpost a patient to if they are short of time in the initial session. \\[37\\] 4. Exercise prescription (~10-15mins): As PNE is most effective when used in conjunction with other therapies, simple exercises should be given to the patient to encourage movement. The patient should perform the exercise during the session and the clinician should discuss the patients perception of the exercise, challenging any inaccurate beliefs utilising the PNE metaphor. Depending on the time available to the clinician this initial session may need to be split into two sessions, however the sessions should then be delivered within a short time frame of each other. The oversensitive alarm clock\\[edit \\| edit source\\] Normal response of nervous system To begin with we must explain to patients the complexity of the nervous system; there are more than 400 individual nerves which all connect like roads, if they were all combined and laid out they would cover more than 45 miles (ref).We can then explain how a healthy nervous system works, introducing the metaphor of an alarm clock: \"When we step on a pin while barefoot we need to know about it so that we can remove the danger and take care of ourselves. The nervous system works like an alarm clock, sending a message to the brain producing pain so that we can take action such as removing the pin from our foot. The alarm will then calm down and is ready to warn you of any future danger such as stepping on another pin.\" Using illustrations will help to explain this metaphor. We can then apply this to the patients presenting problem. Response of a sensitive nervous system We can then explain to the patient that in approximately 1 in 4 people the alarm system does not calm down and stays extra sensitive: \"Before you had the onset of pain the alarm clock had lots of space for activities before the alarm would be triggered but because it is very sensitive there is little room for activities before the alarm goes off. (That explains why your back hurts after standing up for 5 minutes.)\" Again the use of an illustrations can help a patient to understand this. We can then round up the brief introduction by explaining that there is a lot of factors that are contributing to this hypersensitivity, which you can then discuss in later sessions. It is also important that you explain that there are strategies we can use to calm the alarm clock down to give the patient the reassurance that things will get better. \"There are things that are making your alarm clock extra sensitive and also strategies we can use to help calm your alarm clock down. We can discuss these in your later sessions but the main thing is that we start to calm your alarm clock down to give you more room for activities.\" 'Homework'\\[edit \\| edit source\\] It is important that we encourage patients to take an active role in their own recovery. We should provide patients with the relevant tools to enable this and increase their self-efficacy. Giving patients a few simple tasks can help to promote this. These can include: Question Generation: Encourage the patient to write down any questions that they may have regarding pain and the PNE material covered in the session. This helps to remove doubts and increase their understanding of pain experiences. Encourage exercises: Exercise help to enhance movement and increase function. A focus on breathing and relaxation should be emphasised during the exercise with reference to PNE and relaxation of the hypersensitive nervous system. Aerobic exercise: Starting very small in an exercise of their own choice (walking, swimming, cycling, running etc.) patients should be encouraged to participate in aerobic exercise. The benefits should be explained to the patient in terms of the down regulation of the sensitised nervous system. Set goals: Patient should be encouraged to list 5 goals they wish to achieve prior to the next session. Asking the patient “If you could flip a switch and get rid of all your pain, what would you do again?” Clinicians should use their own judgement when giving patient tasks to complete at home, some proactive patients will complete all tasks before the next session, while those with low self efficacy may be overwhelmed when given a large number of tasks. One way to combat this is to give patient 1-2 tasks at a time, a clinician should use their own judgement to determine the tasks to prescribe and what tasks can be introduced in later sessions. Subsequent sessions\\[edit \\| edit source\\] Subsequent session should be individualised to patients and their journey with PNE. The content of these sessions are dependent on what was covered in the previous session e.g. if there was not time in the last session to discuss the importance of aerobic exercise or to teach the patients relaxed breathing techniques then this could be a priority for the next session. A useful structure for later PNE could be: Question and answer: Discuss any questions the patient had about the previous session. If patients do not have any questions the clinician could ask the patient about what they understood from the previous session, this can help identify any areas which patients were unsure of or had forgotten which can then be revisited. Progress PNE: New metaphors, pictures or information can be discussed with the patient. These should be relevant to the patients experience or findings. Review goals: Break the patients goals down into SMART goals. This encourages pacing and graded exposure which can help to motivate patients throughout their journey. Each session the goals should be reviewed, and patient should be encouraged to progress to the next stage if appropriate. Traditional therapy: The clinician should use their own clinical judgement to determine if the patient would benefit from other treatments such as manual therapy. The exercises from previous session should be reviewed and new exercises prescribed to encourage increase function.](https:\/\/www.physio-pedia.com\/Pain_Neuroscience_Education_\\(PNE\\)_for_Low_Back_Pain?utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal)   [Telehealth for Low Back Pain - Physiopedia Introduction Telehealth is defined as the provision of healthcare remotely through the form of telecommunications, such as telephones or laptops. The primary aim of Telehealth is to improve patient's health through education and service provision while reducing healthcare costs and overcoming geographical barriers \\[1\\]\\[2\\]. Telehealth in other conditions has promoted adherence. A study on hospital readmittance reported that 49% of participants who received Telehealth were likely to be readmitted to the hospital compared with 67% of those who did not receive the Telehealth treatment \\[3\\]. In other areas such as Psychology, there is evidence that using video to carry out assessment can work well though there are limitations that can create inaccuracies, including feeling distant to patients and that some patients may not be able to use technology well \\[4\\]. What is Telehealth?\\[edit \\| edit source\\] Figure 1: Video consultation Telehealth is a modality in which a healthcare professional such as a Physiotherapist, Nurse, or Doctor can consult with a patient through video or audio call utilizing a telephone, laptop, mobile phone, or tablet. Telehealth is a term which is used interchangeably with ‘telemed,’ ‘telemedicine,’ ‘telerehabilitation,’ ‘physiodirect,’ and ‘teleconsultation.’ Ultimately, this service allows a healthcare professional and a patient to consult when they are not able to gather face to face for a variance of reasons \\[5\\]. As technology has progressed, the feasibility for Telehealth has progressed too, resulting in some cross-disciplinary behavior theories and models being used to guide the implementation of Telehealth \\[6\\]. These behavior theories help clinicians to understand the patient’s motivation, efficacy, and goals, and allow the clinician to deliver telehealth interventions that meet the patient’s individual needs, complement the patient’s behavior and characteristics, and suits the patient’s unique social environment \\[7\\]. The two primary underlying theories that underpin Telehealth are the self-determination theory and the self-efficacy theory \\[8\\]\\[9\\]. The self-determination theory has been used in health behavior intervention by identifying an individual's motivational blocks and distinguishing between autonomous and controlled motivations \\[8\\]. This theory identifies that incorporating engagement, usability, and acceptance helps to improve self-motivation and engagement in Telehealth \\[10\\]. When there is a low initial motivation to use Telehealth, it is vitally important to evaluate the delivery and ensure individual training and education to increase motivation to engage with telehealth services \\[10\\]. From this, the concept of self-efficacy and one's ability to meet the challenges of self-management and succeed directly impacts Telehealth. Within low back pain patients, self-management is particularly essential. Barriers to self-efficacy include health literacy access and support, which Telehealth directly provides solutions for, thus increasing the patient’s belief and motivation to work towards a successful recovery \\[11\\]. History of Telehealth\\[edit \\| edit source\\] Figure 2\\[5\\] Reasons for Teleconsultations. The term Telehealth originated in the mid-20th century when healthcare professionals would attend to infectious disease patients from a distance using bells and signs. In the 1970s Telehealth developed into what we know it to be today. Initially, NASA needed to solve being able to monitor astronaut’s health while in space. There developed Telehealth through means of video calls. In the 1980s militants on large vessels and workers on oil rigs in the surroundings of the USA would consult with healthcare professionals at the LA medical center through telephone and video call. As it was unrealistic for them to see someone face to face, Telehealth became their best option to get immediate advice. Fast forward to the 1990s, the USA become the largest consumer of telephone consultations, surpassing Norway. In 1996, figure (2) demonstrates what areas these types of consultations were being used for \\[5\\]. Validity and Reliability of Telehealth in Physiotherapy\\[edit \\| edit source\\] Validity is the ability of a measure or modality to achieve what it is intended to achieve. When a modality has high validity, the results can be more trusted or believed \\[12\\]. A randomised control trial conducted in 2014 investigated the validity of Telehealth in lower back pain compared to face-to-face appointments. It found that Telehealth’s validity was varied dependant on the specific element of the assessment, as shown below: Specific Validity Element Telehealth Validity Detection of pain with specific movements High validity Identifying the quality lumbar movement Moderate validity Postural analysis Poor validity Identifying reasons for limitations Poor validity The study concludes that ‘Important components of the standard musculoskeletal assessment of LBP are valid via telerehabilitation in a clinical setting.’ \\[13\\] Reliability is the ability of a measure or modality to achieve the same results when the measure is repeated \\[12\\] \\[14\\]. Specific Reliability Element Telehealth Reliability Inter-rater reliability 0.92-0.96 very good Intra-rater reliability 0.92-0.96 very good Telehealth as a Tool for Assessing Low Back Pain\\[edit \\| edit source\\] Telehealth can be and has been used in the assessment and management of Low Back Pain recently\\[15\\]. There are certain critical aspects of Telehealth that drive success in this area, including that it can encourage early intervention, patient participation, and good communication between clinician and patient \\[3\\]. Tools for Assessments\\[edit \\| edit source\\] The main tools used to perform Telehealth assessments and managements are mobile or device applications, websites, online chats or group discussions, email discussions, phone calls, or a combination of a number of these \\[16\\]. Telehealth has been commonly used in remote populations as these do not have easy access to clinics \\[17\\]. A 2014 study was investigating whether Telerehabilitation is a viable alternative to face-face assessment for patients with low back pain. Twenty-six participants were involved. The study found that there was an agreement in both approaches to identifying pain eliciting movements but poor agreement in identifying reasons for limitation in movement \\[17\\]. There have been several trials investigating the cost-effectiveness of Telehealth triage \\[18\\]. One such study investigating the use of Telehealth when implementing the McKenzie method for assessing and managing low back pain found Telehealth was significantly more clinically effective, and approximately 50% more cost-effective than the clinical based McKenzie treatment \\[16\\]. The main challenge facing the implementation of Telehealth is the limited existence of effective internet service facilities, and the initial engagement from patients is dependant on the adequate technological literacy of the patients \\[19\\]. Another way in which Telehealth aids in assessments is in its use in remote monitoring. Devices can collect physiological data from a distance and rapidly transfer that data to the patient’s cardiologist. Hospitals can have semi-autonomous monitoring of selected patients without the need for nurses to go over to the patient, leading to a 40% reduction in admissions and a significant drop in cost \\[3\\]. A new musculoskeletal assessment framework published in Cureus provides pre-consultation guidance and step-by-step remote examination instructions to musculoskeletal clinicians working in primary care to adapt their assessments based on published evidence, and community-sourced best practice; it also includes patient and clinician resources (patient information leaflet and photographs of examinations)\\[20\\]\\[21\\]. To learn more click on this link: Remote Musculoskeletal Assessment Framework: A Guide for Primary Care Future Improvements to Telehealth Assessments\\[edit \\| edit source\\] The majority of Telehealth facilities are implemented in areas where geographical location greatly restricts the patient’s ability to attend face-to-face consultations. However, very little research has been conducted in metropolitan cities, such as in the UK, where the population is not so sparsely populated. Hence it would be good to see more work carried out in the UK. Furthermore, the majority of the assessment techniques used by clinicians for investigating low back pain are designed for face-to-face environments. This reduces the same assessment techniques reliability when completed in a telehealth setting. More research into the adaption of these techniques into Telehealth appropriate ones, as well as trials to see whether these are effective is needed. There have not been any published studies showing how carrying out a subjective assessment would work using TeleHealth. This is a concern with the patient’s safety and data security affected if a subjective assessment is not entirely feasible within Telehealth. Still, further research needs to be carried out to assess more closely the economic benefits to Telehealth \\[18\\], as well as further advancements in technology to increase the accuracy of telehealth assessment consultation, as even with video consultations, the prefered form of Telehealth for assessing posture, it can still be challenging to discriminate physical landmarks on a video call \\[22\\]. Using Telehealth is a good alternative, but more work needs to be done to improve postural assessments, and further research is needed to see how devices utilising remote monitoring can be applied to LBP patients. Telehealth as a Tool for Management Low Back Pain\\[edit \\| edit source\\] With the advancements of online technology websites and applications have created a new frontier for research into patient’s self-managing their own physical conditions in their home environments. As compliance research shows that between 45-70% of patients are noncompliant with their physiotherapy prescriptions, This new field of Telehealth management promises to increase patient exercise adherence while offering physiotherapists a method to support patient self-management between face-to-face sessions \\[23\\]. The current practice guidelines for managing low back pain can be broken into three major categories: patient education, behavioral therapy, exercise prescription \\[24\\]. All of these could be delivered through telehealth rehabilitation \\[25\\]\\[15\\]. Telehealth is a beneficial intervention, with the best outcomes, in trials investigating walking programs, cognitive-behavioral therapies, education, and group therapy sessions. A systematic review of 11 Randomised Controlled Trials has been conducted with a total of 2,280 participants looking to evaluate whether interventions delivered by Telehealth improve pain, disability, function, and quality of life in Non-Specific Low Back Pain \\[26\\]. The Telehealth interventions in the studies were delivered by telephone and online chats, websites, and emails. An important finding in the study was that those who participated in a tailored self-management web-based program involving education and behavior strategies were near two times less likely to experience LBP symptoms again two months after treatment (1.7 OR) \\[26\\]. Despite this, the only outcome that a significant difference favoring the use of Telehealth was quality of life. The results showed no significant improvement in pain or disability short term in any of the studies (WMD -2.61, 95% CI -5.23-0.01). There was no significant difference in disability. Another randomized controlled trial investigating the effect a telehealth-based mobile application called Snapcare could have on chronic low back pain patient's pain and function. Of the 93 participants recruited, 45 received Snapcare in addition to a written prescription, and 48 received medicine and recommended physical exercise. The was a significant (P\\<0.05) reduction in pain and disability in both groups, and a significantly (P\\<0.001) greater decline in the Snapcare group compared to the control group \\[27\\]. The conclusion is that the telehealth application reminded and promoted the patients to be compliant with their physical activity program, thus facilitating the patient’s recovery by aiding the increase in physical activity. Within the management of low back pain empowering the patient to feel able to self-manage effectively is vitally important to treatment success. Trials investigating the role of Telehealth as a unique intervention in the management of acute low back pain found an educational component that improves the patient’s knowledge of their condition and encourages an active lifestyle, as well as health tracking devices, such as a pedometer, is successful in reducing current pain intensity, depression, anxiety, stress, and duration of pain significantly (P=0.04) \\[28\\]\\[29\\]. Implementing behavioral change approaches such as cognitive behavioral therapy and health coaching principles can be used successfully within Telehealth as well. Compared to usual care alone, combining telehealth strategies with usual care has a clinically significant reduction of pain, disability, and function in patients with subacute low back pain both short and medium-term \\[30\\]\\[31\\], There is conflicting evidence on the effect Telehealth has on chronic low back pain, with moderate-quality evidence reporting there is no significant difference between Telehealth and minimal interventions for reducing short term or medium term pain in chronic low back pain patients \\[30\\]. Some trials have found that Telehealth does not affect chronic low back pain patient's function short or medium term, as a sole intervention or combined with the minimal intervention \\[31\\]. However, when trials investigated telehealth effect on patient's quality of life, Telehealth was significantly superior in improving all patients' quality of life irrespective of the duration of low back pain symptoms or length of follow-up \\[26\\]. For chronic low back pain, Telehealth seems to be suitable when needed but not yet as an undisputed good alternative to face-to-face appointments. Management Options\\[edit \\| edit source\\] The three main Telehealth models for Physical Therapy are \\[32\\]: Live Video (Synchronous): This uses real-time live consultation to treat patients. Store and Forward (Asynchronous): This uses the secure transmission of pre-recorded materials to treat patients. Remote Patient Monitoring: This uses technology to remotely get medical data on the patient’s treatment progress. The various methods of telehealth attempt to comply with all three of these models to ensure the treatment provided are of the best quality, and accessible for all patients. For example, Reflexion Health Inc has developed a telehealth tool called VERA System, which combines all three Telehealth models. It walks patients through exercises, carries out an accurate analysis of movements, and gives real-time feedback. Though not used for treating LBP, it was shown to be of equal benefit as traditional physical therapy in Post Total Knee Replacements Rehab, with the additional benefits of having significantly lower health costs \\[33\\]. Future Improvements to Telehealth Managements\\[edit \\| edit source\\] A major issue affecting the development of Telehealth is that it is as good as the technology is the most available technologies, such as SMS, Apps and Health Trackers, are the least investigated. These have shown some promise in some papers but not specifically enough with LBP. Therefore more research needs to be done to investigate the effects of app-based interventions and fitness trackers especially \\[3\\]\\[27\\]. Also, as more technology has been developed specifically for health purposes, not many quality technologies exist that are transferable to physical therapy. Those that do exist require further testing to know their full clinical benefit. As video calls are the most frequently used telehealth tool more research into whether face to face video management enhances LBP management is required to support its use. There is also a need to investigate multimodal interventions within Telehealth, as the majority of telehealth methods attempt to incorporate the three main models. Trials investigating the relative success of these three models are needed. As with assessment methodology, there is no specific management option with Telehealth and a lot of the studies investigated use such different means it is difficult to come to a clear conclusion \\[26\\]. Confounded upon this is the disagreement within the literature for managing low back pain using Telehealth, with most of the current telehealth-based interventions showing no significant clinically important benefits in the outcomes investigated, particularly for chronic Low back pain. In contrast, research on acute or subacute low back pain has shown promising significantly important benefits in the outcomes measured. The significant benefits Telehealth has on all types of low back pain patient's quality of life, suggests that there is biopsychosocial benefits telehealth has on low back pain patients and demands further study. Telehealth Pros and Cons\\[edit \\| edit source\\] Within Telehealth, there are several pros et contras. One study investigating the use of a Telehealth based website to facilitate health coaching found that participants logged into the website only 38% of the recommended time \\[34\\]. Showing that adherence and compliance to the telehealth interventions were lower than recommended or expected. Within this study, there are some possible explanations to why the adherence to the telehealth treatment was lower than expected. Potentially the patients were becoming disheartened and disinterested as the effects of the treatment on their low back pain were smaller than they might have expected. Also, the technology itself may have been limited and a factor contributing to the higher level of non-compliance than expected. Below is a break down of the most common advantages and disadvantages that Telehealth offers to physiotherapy, particularly in the management of low back pain. Pros Cons Telehealth provides an alternative solution for people who live in remote areas and are not always able to travel. Poor patient compliance is associated with using telehealth \\[35\\]. Telehealth makes healthcare accessible to everyone, as long as there is an internet connection, even during a global pandemic like 2020. Patients often decline to use Telehealth due to preferring face to face contact. Telehealth provides a means to use new technology to enhance health services \\[26\\]. May lead to fragmentation of care amongst multiple providers. Telehealth is effective in managing health conditions such as obesity and asthma. There may be a lower quality of the patient-clinician relationship Telehealth reduces healthcare costs by improving efficiency and revenue. Patients may have a lack of access to the necessary technology. Telehealth offers a better possibility of continuity of care. There is a high initial cost of acquiring the technical equipment. Telehealth can ease the global burden of low back pain, which has a high prevalence rate of 39% worldwide \\[36\\]. Many argue its overall effectiveness for dealing with chronic Low Back Pain is limited. Telehealth has been shown to significantly improve patients quality of life, particularly patients with chronic low back pain. Telehealth may be detrimental to clinicians establishing patient rapport. Patients had increased compliance with their treatment exercises \\[27\\]. Conclusion\\[edit \\| edit source\\] Telehealth has very high validity and reliability suggesting there is a clinical use. From a moderate amount of research, there is some benefit to using Telehealth to manage patients with low back pain, but there is still a need for more research. Within physiotherapy telehealth is a relatively new area of study, still requiring the development and testing of specific assessment and management approaches to treating certain conditions. Within telehealth research, the patient satisfaction scores and patient quality of life scores are significantly higher within telehealth interventions groups. Despite this, there is still a public concern associated with Telehealth. Many patients may not fully understand the breadth of physiotherapy and what is included within physiotherapy treatment, assuming that physiotherapy requires physical contact. With the COVID-19 pandemic, telehealth has played an essential role in enabling physiotherapy clinics to continue semi-functioning during global lockdowns. Telehealth has enabled infections to be avoided while still maintaining contact with patients ensuring exercises are being adhered to. There is a vital role Telehealth plays in sparsely populated communities where the distance between clinical facilities and patients is too great or dangerous for either patient or clinician to traves. The research has shown that Telehealth can be an effective supplement to usual physiotherapy, rather than a replacement. The future of Telehealth seems promising, with the continual developments and improvements of current technologies, hopefully, followed by more researcher, from all areas of the world, taking an active interest in Telehealth biopsychosocial, hygienic, and economic benefits. Consequently, further clinical trials and systematic reviews will be carried out broadening and deepening the pool of research to base the management of low back pain using Telehealth.](https:\/\/www.physio-pedia.com\/Telehealth_for_Low_Back_Pain?utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal)   [Fitness and Low Back Pain - Physiopedia Introduction Low back pain (LBP) is an umbrella of conditions with 80% of adults estimated to experience LBP at some point during their life \\[1\\]. Low back pain refers to pain between the bottom of the ribs and the buttock crease. A high physical fitness level, and especially muscle endurance in the back muscles, is associated with lower risk of back pain\\[2\\] A harmful misconception is that exercise should be avoided when LPB is present. Understandably, many patients are reluctant to exercise out of the fear that any exercises or stretching will aggravate their existing back pain. They may become reluctant to exercise and rely on medications.\\[3\\] Physical activity (PA) to increase aerobic capacity and muscular strength, especially of the lumbar extensor muscles, is important for patients with chronic LBP in assisting them to complete activities of daily living.\\[4\\] This article focuses on non specific chronic low back pain (NSCLBP) and its relations with fitness. Fitness \\[edit \\| edit source\\] Plank exercise, core activation Physical fitness is a set of attributes that people have or achieve. Being physically fit has been defined as the ability to carry out daily tasks with vigour and alertness, without undue fatigue and with ample energy to enjoy leisure-time pursuits and meet unforeseen emergencies\\[5\\] Being physically fit depends on how well a person fulfils each of the components of being healthy.When it comes to fitness, these components are\\[6\\]: Cardiorespiratory Endurance - VO2 max per Kg of body mass \\[7\\] Muscular Endurance - Currently no Gold Standard measurement for muscular endurance Muscular Strength - There are a number of ways to measure muscular strength. The Biering-Sorenson Test. is an easy to perform test for back strength. Isokinetic Dynamometry is the gold standard re back strength but is very expensive. \\[8\\] Body Composition:- The current Gold Standard is a Four-Compartment model of measurements most commonly consisting of Mass, Total Body Volume, Total Body Water and Bone Mineral Content.\\[9\\] Flexibility - Optical Gold Standards such as the Vicon Motion Tracking System\\[10\\] The following sections will look at each of these components individually, relating it to LBP. Cardiorespiratory Endurance\\[edit \\| edit source\\] Cardiorespiratory endurance indicates how well the body can supply fuel during physical activity via the body’s circulatory and respiratory systems. Aerobic activities that help improve cardiorespiratory endurance are those that cause an elevated heart rate for a sustained period of time. eg swimming, brisk walking, jogging, cycling\\[6\\] LPB relevance Aerobic exercise increases the blood flow and nutrients to the soft tissues, including those in the back, hastening the the healing process. Thirty minutes of aerobic exercise increases the body’s production of endorphins, a natural alternative for pain relief for the body. This helps with clients pain levels and may reduce reliance on medication for pain. A low aerobic fitness level is associated with CLBP Maximum oxygen consumption (VO2max) is found to be significantly lower by 10 mL\/kg in men and by 5.6 mL\/kg in women with CLBP compared to men\/women without.\\[3\\] Muscular Endurance \\[edit \\| edit source\\] Biering-Sorenson Test Fitness also includes muscular endurance, which is the ability of a muscle to continue exerting force without tiring.\\[6\\] Patients with low back pain have reduced lumbar extensor muscular endurance in comparison with non-sufferers.\\[11\\] \\[12\\]See Biering-Sorenson Test. Abdominal muscular endurance in low back pain sufferers is significantly decreased in contrast to those in the normal health population \\[13\\] Lumbar fatigue as a result of low muscular endurance has been shown to reduce the person’s ability to sense the positioning of the lumbar spine. People with chronic LBP have impaired ability in controlling the position of the lumbar spine after a fatiguing task, leading to lumbar instability.\\[14\\] Patients with lower back pain, have a higher percentage of fast type I glycolytic fibres compared to the slow oxidative fibres. Fast twitch fibers contract quickly but get tired quickly, rendering them less resistant to fatigue. This makes these people more susceptible to back injury. Non-LBP people have a much higher percentage of slow twitch fibers, which are best for endurance work, as they can carry out tasks without getting tired, and are present in core muscles.\\[15\\]\\[6\\] Strength and Low Back Pain\\[edit \\| edit source\\] Back extensors at work. The core is the group of trunk and hip muscles that surround the spine, abdominal viscera and hip. Core muscles are essential for proper load balance within the spine, pelvis, and kinetic chain. Core strengthening\\[16\\] has a strong theoretical basis in treatment and prevention of LBP, as well as other musculoskeletal afflictions. A reduction in core strength can lead to lumbar instability.\\[3\\] Muscle strengthening exercises form part of the NICE treatment guidelines for Early management of persistent non-specific low back pain. The importance of the core relate to its function ie sparing the spine from excessive load and transfer force from the lower body to the upper body and vice versa. Having a strong, stable core helps us to prevent injuries and allows us to perform at our best. In order to protect the back, ideally we want to create 360 degrees of stiffness around the spine as we move, run, jump, throw, lift objects and transfer force throughout our body. We do this when all of the muscles in our hips, torso and shoulders work together\\[17\\] Exercises to activate the deep abdominal muscles including the superficial muscles, transversus abdominis muscle and the multifidus are important for CLBP patients\\[3\\]. Measures of Back Strength: For information here look at Physiotherapy Assessment section of Core Stability Few of us will have access to a isokinetic machine to measure trunk strength, as shown in video below. \\[18\\] Body Composition \\[edit \\| edit source\\] Obesity can lead to altered body positions eg exaggerated lumbar lordosis The body is composed of water, protein, minerals, and fat. A person can potentially maintain the same weight but radically change the ratio of each of the components that make up their body. A two-component model of body composition divides the body into a fat component and fat-free component. Body fat (storage fat) in excess can increase susceptibility to chronic illness, health complications, and LBP. Numerous studies have been conducted highlighting the relationship between increased fat content and the likelihood\/prevalence of lower back pain. A study conducted in 2003 \\[19\\] found that there was a moderate positive relationship between obesity and lower back pain, however the results were based on the BMI calculation which does not definitively measure body fat content. In a study conducted by Urquhart 2011 which took into account the amount of body storage fat\\[20\\] and it was evident that there was a relationship between obesity and lower back pain An increase in body weight alters spinal biomechanics and loading, creating excess strain to be put through certain structures eg Obesity can lead to altered body positions such as exaggerated lumbar lordosis which will cause an alteration in spinal loading mechanics. Flexibility\\[edit \\| edit source\\] Flexibility refers to the range of movement across a joint. Flexibility is important because it improves the ability of the kinetic chain to work smoothly and can help prevent injuries. It is specific to each joint and depends on a number of variables, including the tightness of ligaments and tendons. Stretching Relevance to CLBP Stretching the soft tissues in the trunk and lower limb eg Back and thigh muscles and the regions ligaments and tendons. This can help to mobilize the spine, and improve the range of motion of the spine, decreasing back pain. Stretching exercises decrease the muscle stiffness as a result of changes in viscoelastic properties, due to the decreased actin-myosin cross-bridges and the reflex muscle inhibition.\\[3\\] Improved range of motion assists in the spine and related areas improves the ability to complete ADLs eg lifting and bending which require trunk flexion, a complex interaction combining lumbar and hip motion\\[3\\]. Spasmodic or shortened back muscles adversely affect the complex spinal mechanics \\[21\\]. Tightness in the hip flexors and hamstrings can lead to a Lumbar hyperlordosis, predisposing patients to lumbar facet syndrome\\[22\\] Exercises to Decrease Low Back Pain\\[edit \\| edit source\\] It has been showed by numerous studies that exercise therapy decrease low back pain and improve overall functional mobility. Here are some methods which help to decrease low back pain. Aerobic exercise\\[edit \\| edit source\\] Aerobic exercise increases the blood flow and nutrients to the soft tissues, including those in the back, hastening the healing process. low impact exercise elevates the heart rate without worsening the back pain. Exercise like walking or cycling help to improve circulation, strengthen the muscle of legs and back, reducing the stiffness and pain in the back. swimming is another great aerobic exercise that improve cardiovascular endurance, a full body workout which improve flexibility and muscular endurance. Stretching and Strengthen Exercise\\[edit \\| edit source\\] postural exercises have improved pain control and improve functional mobility on low back patient. Knee to Chest Stretch Bridges Exercise Cat and Cow Stretch Seated Lower Back Rotational Stretch lumbar rotation In acute low‐back pain, exercise therapy is as effective as either no treatment or other conservative treatments.\\[23\\] Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low‐back pain, particularly in healthcare populations.\\[23\\] Conclusions\\[edit \\| edit source\\] Importance of Fitness A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain concluded thus: A general exercise programme that combines muscular strength, flexibility and aerobic fitness is beneficial for rehabilitation of non-specific chronic low back pain. Increasing core muscular strength can assist in supporting the lumbar spine. Improving the flexibility of the muscle-tendons and ligaments in the back increases the range of motion and assists with the patient’s functional movement. Aerobic exercise increases the blood flow and nutrients to the soft tissues in the back, improving the healing process and reducing stiffness that can result in back pain.\\[3\\] And remember the important message is that embarking on any regular exercise will be of benefit to an overall person’s health including reducing back pain. With exercise they will look and feel better.\\[6\\]](https:\/\/www.physio-pedia.com\/Fitness_and_Low_Back_Pain?utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal)   [Aquatic Therapy in the Management of Chronic Low Back Pain - Physiopedia Introduction Chronic low back pain (CLBP) is a very prevalent condition, affecting millions of people worldwide.\\[1\\] It is also one of the leading causes of disability. \\[2\\] Aquatic therapy is a popular treatment modality for those with musculoskeletal and neurological conditions due to the unique properties of water which confer benefits. \\[3\\] Both of these topics are covered separately on Physiopedia pages but have yet to be combined in one page. This page aims to present the research so clinicians can be more informed and potentially offer aquatic therapy as a treatment modality for those with CLBP. Low Back Pain Classification by Duration:\\[edit \\| edit source\\] Acute low back pain: 6 weeks or less Sub-acute low back pain: 7-12 weeks Chronic low back pain: More than 12 weeks \\[4\\] Chronic Low Back Pain\\[edit \\| edit source\\] Chronic low back pain refers to pain persisting for longer than three months, even after the initial injury or underlying cause of acute low back pain has been treated. \\[5\\]\\[6\\] There are two further classifications: Non-specific Low Back Pain is defined as \"pain, tension, soreness and\/or stiffness in the low back region between the lower margin of the 12th rib and the gluteal folds which is not attributed to any recognisable pathology\". \\[7\\] Non-specific low back pain affects approximately 90% of all patients with low back pain. \\[8\\] Specific Low Back Pain, these pathologies can be classified as followed: \\[9\\] Disc herniation Spondylolisthesis Lumbar muscles or spinal ligament strain\/ sprain Scoliosis Osteoporosis Ankylosing spondylitis Cauda equina syndrome Scheuerman's Kyphosis Epidemiology\\[edit \\| edit source\\] Image 1: Age distribution of chronic low back pain from 2008 to 2018 in United Kingdom (World Bank, 2020)\\[10\\] Low back pain (LBP) affects approximately 7.5% of the global population (577.0 million people) of those, 5-10% of all LBP patients will develop CLBP. \\[11\\] Specifically, in the United Kingdom, this accounts for 1\/3 of all adults and is the leading cause of disability. \\[12\\] In all age groups, the prevalence and number of people living with LBP has continually increased between 1990 to 2017. \\[13\\] Even though the prevalence of LBP increases with older age, the greatest number of people with LBP are currently in the 50 to 54 year-old age group. \\[13\\] CLBP is more common in women, those of lower socioeconomic level, people with lower education status, and smokers. The incidence appears to have increased over time. This might be due to significant changes in lifestyle and work environment.\\[14\\] A family history of severe back pain, radiating pain, recommendation to rest after a back pain consultation, occupational LBP, or LBP caused by a traffic accident are all linked to chronic disabling back pain over the course of a lifetime. \\[15\\] The development of CLBP is also influenced by job satisfaction and psychological variables. Anatomical Relevance\\[edit \\| edit source\\] Lumbar Lordosis The lumbar spine consists of five lumbar vertebrae (L1-L5). The vertebrae form a slightly inward curve known as lordosis. These vertebrae are connected by facet joints; which allow for lumbar flexion, extension, rotation and lateral rotation.\\[16\\] Lumbar Spine Pathology\\[edit \\| edit source\\] The lumbar spine's two lowest segments, L5-S1 and L4-L5, bear the greatest weight and move the most, rendering them vulnerable to injury. In between the vertebral bodies, are the intervertebral discs that provide flexibility to the spine, maintaining the height between the vertebrae and distribute compressive loads by acting as shock absorber. As a result of aging, the discs may become less flexible and dehydrated, thus more prone to tearing. \\[17\\] This makes them more likely to herniate or degenerate which can cause pain in the low back. Studies also found many patient with CLBP has disc degeneration. \\[18\\] The lumbar region also contains large muscles that support the back and allow for movement in the trunk of the body when working together with the abdominal, the gluteal and the leg muscles. These muscles can strain or spasm which is also another common cause of low back pain. \\[19\\] Pathological changes\\[edit \\| edit source\\] Some studies suggests that para-spinal and multifidus muscle groups are significantly smaller in patients with CLBP than in healthy patients.\\[20\\] They believe, patients with persistent unilateral LBP, that this will present on the symptomatic side. \\[21\\] These finding can further explain in 2 aspects (Microscopic \\[22\\] and Macroscopic \\[22\\]). Microscopic change\\[edit \\| edit source\\] It has been reported that patient with severe CLBP have a higher portion of type IIB muscle fibre (fast twitch glycolytic) at the expense of type I muscle fibre (slow twitch oxidative). \\[23\\] In healthy population, the paraspinal muscles have been found to have more type I muscle fibre in comparison with other skeletal muscle. The alteration in fibre type in severe CLBP, could lead to lowered fatigue resistance of the paraspinal muscles which will result in higher vulnerability of the lumbar spine and cause pain.\\[24\\] Macroscopic change\\[edit \\| edit source\\] CLBP can affect muscle structure by compromising muscle function. Comprised muscle function due to pain can alter muscle structure, including reduce muscle cross section and increase fat infiltration.\\[25\\] Pain-related nerve inhibition reduces lumbar muscle activity in order to prevent tissue damage and lead to muscle inhibition and atrophy. Clinical Presentation\\[edit \\| edit source\\] Dull and achy pain that is contained to the low back region Worsening pain after prolonged sitting or standing Muscle spasms and tightness in the pelvis, low back and hips Burning and \"electrical shock\" like pain that radiates from the low back to the back of the thighs and\/ or the lower extremities Difficulty standing up straight, bending and walking \\[26\\] Prognostic Indicators\\[edit \\| edit source\\] The importance of prognostic factors\\[edit \\| edit source\\] By determining which variables are prognostic outcomes, clinicians gain insight on the biology and natural of the disease Appropriate treatment strategies may be optimised based on the prognostic factor Prognostic factors are often used in the design, conduct and analysis of clinical trials Patient and their families are informed about the risk of recurrence or future development of the disease \\[27\\] Prognostic indicators for poor outcomes in CLBP\\[edit \\| edit source\\] \\*If odds ratio\\> 1: odds of exposure among cases is greater than among controls (a positive association between disease and exposure) \\[28\\] Table 1. Examples of predictor factor of CLBP and related clinical evidence. Working status (Active\/ not working) Types of work The physical intensity of work, especially strenuous physical work, working in difficult working positions and carrying heavy loads was related to higher chronicity. \\[29\\] \\[30\\]\\[31\\] In a case-crossovers study with 12-months follow up, the carrying of heavy loads was predictive for CLBP with an Odds ratio of 8.0 (95% CI 2.8-22.6). \\[32\\] Smoking Smoking has been prove to be major predictor of the chronicity of CLBP. Odd ratio for smoking varied between 2.49 (95% CI 1.15-5.40)and 4.41 (95% CI 1.50-12.95) which showed positive correlation. \\[33\\] Obesity Positive correlation between obesity and chronicity of CLBP. The odd ratio differed between 1.075 (95% CI 1.023-1.128) and 1.21 (95% CI 1.04-1.41) in women and between 1.091 (95% CI 1.027-1.158) and 1.16 (95% CI 1.05-1.29) which showed there are positive correlation. \\[31\\]\\[34\\] Referred leg pain (yes\/ no) LBP with any leg pain tended to be more severe than local LBP only, regardless of how severity was measured, and was also associated with higher frequencies of psychological risk factors. \\[35\\] Maladaptive psychosocial factors Depression was the most studied factor in predicting chronicity. Henschke et al.\\[36\\] and Shaw et al. \\[33\\]reported statistically significant positive relationship between depression and the chronicity of LBP. Main prognostic indicators for the disability of CLBP\\[edit \\| edit source\\] In a cohort study (n=1760) aiming to identify clinically important prognostic factors of disability in CLBP, younger age, less disability at baseline, shorter duration of back complaints at baseline, and higher baseline scores on the SF-36 Physical component Summary and Mental Component Summery were reported as predictors of absolute recovery (Quebec Back Pain Disability Scale score ≤20 points) at both 5- and 12-month follow-ups. \\[37\\] Main prognostic indicators for the chronicity of CLBP\\[edit \\| edit source\\] A recent systematic review of 25 studies reported that high pain intensity, carrying heavy loads at work, higher body weight and depression were the most frequently observed risk factors for CLBP. Maladaptive behaviour strategies, general anxiety, functional limitation during the episode, smoking, and particularly physical work were also explicitly predictive of chronicity. \\[38\\] Aquatic Therapy\\[edit \\| edit source\\] What is Aquatic Therapy?\\[edit \\| edit source\\] Group Aquatic Therapy Session Aquatic therapy can be defined as “A physiotherapy programme utilising the properties of water, designed by a suitably qualified physiotherapist”.\\[39\\] This treatment method involves various exercises in water which should be carried out by appropriately trained therapists in a heated, purpose-built hydrotherapy pool. The use of aquatic therapy is popular amongst patients with musculoskeletal and neurological disorders. \\[3\\] Patients report benefits of increased strength, flexibility, mobility, as well as decreased pain levels.\\[40\\]. These benefits are resultant of the unique properties of water, and therefore cannot always be replicated through land-based exercise. Unique Properties of Water\\[edit \\| edit source\\] Water Density\\[edit \\| edit source\\] The water density counterbalances the effect of gravity which allows the human body to float. This buoyancy effect offers support allowing less impact on joints. This is valuable during rehabilitation as it allows patients who are experiencing pain, to exercise with reduced loading through the joints. Additionally, this buoyancy effect controls the downwards movement of the body and therefore decreases the need for eccentric control. \\[41\\] Exercises such as walking, jogging, or running which may be painful to patients, can now be performed in water with less impact on the joint and therefore less pain. For spinal patients this causes reduced axial loading and joint stress on the spine. Natural Resistance of Water\\[edit \\| edit source\\] Water has a natural resistance as a result of its density and viscosity. This allows for effective strengthening during rehabilitation treatment sessions. The intensity of the resistance can be manipulated as well to fit the individual needs of the patient. Altering depth of submergence, speed of exercises performed, and the surface area of the body can affect the resistance profile of the water. For example, when stationary there is less resistance from the water on the body. However, during high-speed movements, the resistance from the water will increase. Therefore, high speed resistance training can be performed in water allowing for strength to be built with low impact on the joints. As a result, aquatic therapy can be used as an alternative to land-based strength exercise. \\[41\\] Water as a Compressor\\[edit \\| edit source\\] When a patient is submerged in water, they are subjected to hydrostatic pressure. This pressure has resultant effects on the body. For example, increased blood flow and circulation. This allows for greater oxygen delivery to the muscles and relaxation. Hydrostatic pressure can also compress the chest wall which alters pulmonary function and respiratory dynamics. As a result, work of breathing is increased by around 60% compared to that on land. This can actually strengthen respiratory muscles and improve the aerobic fitness of individuals. \\[41\\] Temperature\\[edit \\| edit source\\] Hydrotherapy pools are usually heated to between 28-32 degrees Celsius. When submerged, this warm pool temperature can increase blood flow and range of motion. It can also produce greater muscle elasticity which can be beneficial for patients experiencing tightness of the muscles, stiffness or spasticity.\\[41\\] Indications, Contraindications and Precautions to Aquatic Therapy\\[edit \\| edit source\\] Indications\\[edit \\| edit source\\] Management of muscle tone problems Decreased range of movement Decreased muscle strength Reduced balance Joint instability Pain Gait re-education Decreased sensation Neurological patients Patients who are willing to self-manage through a water-based exercise programme which they can continue with in pools available in leisure centres Patients who would benefit from aquatic physiotherapy in the short-term to then progress to land-based exercise when ready \\[42\\] This would include conditions such as: Fibromyalgia Hemiplegia Cerebral palsy Ankylosing spondylitis Juvenile idiopathic arthritis Parkinson’s Disease Obesity CLBP Multiple sclerosis Traumatic brain injuries Stroke Rheumatoid arthritis Contraindications\\[edit \\| edit source\\] Absolute Contraindications\\[edit \\| edit source\\] Patients with the following are not suitable to receive aquatic physiotherapy: Acute systemic illness\/pyrexia Acute vomiting or diarrhoea Medical instability following an acute episode e.g., CVA, DVT Chlorine or bromine allergy Resting angina Shortness of breath at rest Uncontrolled cardiac failure Open infected wounds \\[43\\]\\[44\\] Relative Contraindications\\[edit \\| edit source\\] Known aneurysm Poorly controlled epilepsy Open wounds Thyroid deficiency Neutropenia Weight in excess of evacuation equipment limit Oxygen dependency Unstable diabetes – blood sugar may drop \\[43\\] \\[44\\] Precautions\\[edit \\| edit source\\] Incontinence of urine\/faeces Epilepsy Hypotension Renal failure Poor skin integrity Risk of aspiration Prone to blackouts Sickle cell anaemia Tracheostomy Fear of water Pregnancy is water temperature exceeds 35°C Low calorie intake Equipment Used in Aquatic Therapy\\[edit \\| edit source\\] Resistance Aids\\[edit \\| edit source\\] Flippers\/fins Aquatic Dumbbells Wrist and Ankle Weights Submersible Steps Equipment used in aquatic therapy - kickboards Floatation Aids\\[edit \\| edit source\\] Pool Noodles Aqua round body support Floatation Belts Arm Bands Kick boards Aqua Plinth Sensafloat Underwater Treadmill Cardiovascular Equipment\\[edit \\| edit source\\] Underwater Treadmill Underwater Stationary bike \\[45\\]\\[46\\]\\[47\\] Benefits of Aquatic physiotherapy\\[edit \\| edit source\\] Improved flexibility Improved balance Improved physical function Increased muscle strength and endurance Enhanced aerobic capacity Relaxation Increased mobility Decreased pain levels Improved Quality of Life \\[48\\]\\[49\\]\\[50\\]\\[51\\]\\[52\\]\\[53\\] Assessment and Diagnosis\\[edit \\| edit source\\] During the initial assessment, as recommended in the international back pain guidelines, it is important to examine the patient to diagnostically triage their presenting condition. \\[54\\] This includes screening patients with any new onset of back pain for red flag diagnosis (i.e. neurologic compromise, inflammatory disease, infection, trauma\/ fractures, and cancer which may require emergency attention). \\[55\\] Additionally, it is important to identify other pathology or non-specific causes of back pain. NICE guidelines recommends considering using risk stratification such as the STarT Back risk assessment at first point contact for any new episodes of LBP (with or without sciatica) for shared decision-making. \\[55\\] Subjective History\\[edit \\| edit source\\] Undertaking a subjective history allows to build a rapport with your patient, gain a further insight into their LBP such as onset, duration, location, character, severity and aggravating and relieving factors in addition to identifying serious pathologies. Physical Assessment\\[edit \\| edit source\\] A physical assessment will follow the subjective history to clinically reason and confirm hypothesis. A physical assessment for the lower back will include the following: Observation – posture, abnormal deformity, and curvature Palpation – along spinous process and transverse process, musculature, sacroiliac joint Gait – through stance and swing phase Range of Motion – Passive and Active of lumbar, thoracic spine, and hip Muscle strength – Lumbar spine and Hip Neurological testing – Reflexes, Motor and sensory testing, straight leg raise, femoral nerve test Testing SIJ and Hip – thigh thrust test, pelvic compression, FABER’s Motor control testing – Waiter’s Bow, Pelvic tilts Imagining is not routinely offered in non-specialist setting for people with low back pain – NICE \\[54\\]\\[55\\] Patient-reported outcome measures\\[edit \\| edit source\\] Using patient-reported outcomes provides a patient's perceptive of their disease and treatment which we may not be able to gain through the subjective and objective assessment. It allows patients to track their progress, measure quality of care and management and provides motivation and adherence to treatment. \\[56\\] \\[57\\]\\[58\\] In a 2016 Delphi survey \\[59\\] which included an international multidisciplinary group of researchers, clinicians and patients updated the set outcome domains for LBP. These domains are mentioned below with the associated outcome measures with the best psychometric properties. Choosing the domain and outcome measure during clinical assessment will depend on various different factors such as the patient's level of function, disability and goals. It is recommended to use one of these measures due to reasons mentioned above considering the practitioners personal preference, practical aspects e.g. costs and availability \\[58\\] Physical function – Oswestry Disability Index or Roland Morris Disability Questionnaire Pain intensity – Numerical Rating Scale or Visual Analogue Scale Health-related quality of life – Short Form Health Survey 12 or EuroQol-5D-3L Work – Work Ability or Work productivity questionnaire Psychological functioning – Hospital Anxiety and Disability Scale Pain interference – Pain Interference subscale of the Brief Pain Inventory Psychosocial Effects of Chronic Low Back Pain\\[edit \\| edit source\\] Background\\[edit \\| edit source\\] Known predictors of chronicity and disability in patients with LBP include; depression, distress, and somatisation. \\[60\\] Psychological factors that are associated with all chronic pain include depression and anxiety, fear avoidance, low self-efficacy, and post-traumatic stress disorder \\[60\\] \\[61\\] \\[62\\]. Finally, social factors include abstaining from work, detaching and isolating from others and compensatory mechanisms. \\[60\\] The Biopsychosocial Model of Chronic Pain\\[edit \\| edit source\\] Numerous psychosocial factors are associated with CLBP, therefore a biopsychosocial perspective is important to provide optimal care. \\[63\\] The biopsychosocial model of back pain is based on a holistic view which recognises the reciprocal influences of the biological, psychological, and social variables that influence LBP. Due to the variable human experiences of back pain, this is vital to understand. \\[64\\] Demonstrated in the image below. Bio: physiological pathology Psycho: behaviours, thoughts and emotions such as psychological distress, fear\/avoidance beliefs, current coping methods and attribution Social: socio-economical, socio-environmental, and cultural factors such as work and family BPS Model of Chronic Low Back Pain Duenas \\[65\\] explains that chronic pain causes significant consequences for not only patients but their professional and social environment and therefore both social and psychological domains are important to understand. \\[65\\] Psychosocial Factors Influence Ones' Life\\[edit \\| edit source\\] Psychosocial factors cause a continuous detrimental cycle whereby they not only affect the back pain but also one’s life. For example, depressive symptoms may worsen back pain and therefore increase the disability associated with back pain. \\[63\\] Back pain patients are more likely to experience: Anxiety disorders Major depressive disorders The coexistence of these conditions and associated back pain may lead to decreased quality of life and a greater chronicity. Despite this, mechanisms of the associations that underly CLBP are still not fully understood. \\[66\\] Avoidance Behaviour - Anxiety\\[edit \\| edit source\\] There are two pathways in which people may take when experiencing LBP. The first is that they continue their daily life by moving normally, which intern helps the recovery process. However, the other pathway evolves when a patient begins to avoid movements, potentially due to pain-related fear, anxiety, or to seek safety. This can lead to cycles of greater disability and increasing pain, and thus the maintenance of chronic pain. This is described in the Fear Avoidance and Beliefs Model (FAMB). \\[67\\] Fear Avoidance and Beliefs Model Low Back Pain and Depression\\[edit \\| edit source\\] A study by Robertson \\[68\\] with 1013 first year Canadian university students looked at the association between LBP and depression and somatisation in adults. Participants completed the modified Zung Depression Index, the modified somatic perception questionnaire and a survey about low back pain and intensity. Results revealed over 50% of subjects reported LBP across grades, and both depression and somatisation was positively associated with LBP, consistent with other studies and reinforcing the understanding of the detrimental association. \\[68\\] Summary\\[edit \\| edit source\\] The deleterious cycle of psychosocial factors and CLBP impact many people worldwide. Psychosocial factors not only impact back pain but also play a role in how the pain impacts one's life. Therefore, it is important to be aware of the psychosocial element that plays such a huge role in the assessment, management and treatment of LBP. For example, use psychosocial outcome measures with patient to measure their current presenting condition and improvements (HADS), as discussed previously. The Effectiveness of Aquatic Therapy for Chronic Low Back Pain\\[edit \\| edit source\\] The standardised approach for the management of CLBP is multi-modal. The NICE guidelines recommend: \\[55\\] Self-management Advice and information from health care professionals to allow patients to self-manage their pain Activity modification Information about the nature of their back pain Exercise Type of exercise should take into account the patients' specific needs, preferences and capabilities Group exercise programmes are recommended Manual Therapy Spinal Manipulation, mobilisation and soft tissue techniques in addition to exercise Psychological therapy CBT approach for managing LBP in addition to exercise Consider a combined physical and psychological programme Promote and facilitate return to work and normal activities Pharmacological approach Oral NSAIDs Lowest effective dose for the shortest amount of time Weak opioids if NSAIDs are contraindicated Within these NICE guidelines the importance is placed upon exercise and making sure the type of exercise takes into account the specific needs and preferences of the individual patient. Often, patients are prescribed land-based exercises focusing on strengthening, stretching and motor control. However, when walking or moving on land, our spine gets compressively loaded due to gravity and body positions which can increase intradiscal pressure. \\[69\\]\\[70\\] This is important to note because increased of loading of the facet joints, and other spinal structures has been suggested as a potential cause LBP. \\[71\\] Pressure on Lumbar Discs based on body position This is why it is important to consider alternative treatment options to land-based exercise which decrease this spinal loading. For example, aquatic therapy can be indicated as a management option for CLBP because the unique properties of water allow for exercise in a medium which reduces pressure on joints. The main benefits of aquatic therapy for CLBP are: Decreased Pain Increased Function Decreased Disability Aquatic therapy for improving pain\\[edit \\| edit source\\] As previously stated, aquatic therapy can have benefits for CLBP by decreasing patients self-reported pain levels. In research, this is often measured using visual analogue scales (VAS). A randomised control trial by Baena-Beato et al.\\[72\\] researched the effect aquatic therapy had on sedentary patients with CLBP. The 49 participants were split into aquatic therapy and waiting list groups who received advice and education (control). Results found that after 2 months of the aquatic therapy programme, participants experienced significantly improved LBP (VAS) at rest, and lumbar flexion and extension compared to the control group. Body composition was also measured, with weight and BMI decreasing for the aquatic therapy group compared to the control. However, this was a small sample size and only evaluated sedentary patients which could impact the generalisation of these results to the wider population. Aquatic therapy decreasing pain for patients with CLBP has been supported by a systematic review and meta-analysis Shi et al.\\[73\\] This review included 8 trials with a total of 331 participants, looking at the effectiveness of aquatic therapy for CLBP patients. Sessions ranged from 2-5x a week and from 30-80-minute sessions over a period of 4-15 weeks. Comparison groups either received land-based therapy, standard general practice, or no exercise. Results showed that patients who took part in aquatic therapy experienced a statistically significant reduction in self-reported pain (VAS) compared to the control groups. However, these changes were not always reported as clinically significant. Aquatic therapy for improving disability and function\\[edit \\| edit source\\] CLBP is one the leading cause of disability worldwide.\\[2\\] As a result, physical function is compromised, and patients often struggle to complete their activities of daily life and work-related activities. Aquatic therapy aims to improve these two symptoms of CLBP. A randomised control trial by Dundar et al.\\[74\\] assessed 65 patients with CLBP. They were randomly assigned aquatic exercise or land-based exercise. After 4 weeks, both groups improved in all outcome measures compared to baseline. However, the aquatic exercise group showed a significantly better improvement in the Oswestry Low back pain disability questionnaire and the physical function section of the SF36. This was further supported by a systematic review. \\[75\\]A total of 7 trials were included in the review, and results showed that compared to no intervention, aquatic therapy resulted in a significant improvement in function (Oswestry Disability index). However, the improvements were no better than other interventions. Aquatic Therapy vs Other Therapies\\[edit \\| edit source\\] Land-based therapy is recommended for patients with LBP as an intervention to increase range of motion, flexibility, and strength. As mentioned above, aquatic therapy has a wide range of benefits on patients with LBP. Here are two studies comparing aquatic and land-based therapy for patients with LBP: A study by Hend et al. \\[76\\] conducted a randomised control trial comparing aquatic therapy (n=30) to land-based therapy (n=30) on pain level, functional ability, and lumbar range of motion in CLBP patients. In a population of 60 participants, on multivariate analysis, a statistically significant multivariate effects were found for the main effects of groups for time and interaction between groups and time. Additionally, on univariate analysis, a statistically significant difference (p\\<0.05) between the groups were observed, favouring the aquatic group for VAS, ODI, flexion, extension, and side flexion outcome after 4 weeks. Land-based exercises did show statistical improvements in pain intensity, ODI and lumbar flexion however no difference was observed in extension and right and left side flexion with aquatic therapy group showing significant results in all outcome measures. However, this study had no control group and did not evaluate the long-term effects of using water-based therapy therefore could have been impacted by bias reducing its validity and reliability. Another randomised control trail by Peng et al. \\[77\\] compared aquatic therapy to physical activity modalities (TENS). In a population of 113 participants, they were split into aquatic group (56) and physical therapy modalities group (57). After treatment for 12 weeks, which comprised to 60-minute sessions twice per week for a total of 24 sessions, a statistically significant clinically meaningful improvement was observed in disability scores (Roland Morris) in the aquatic group compared to physical modalities after 3, 6 and 12 months (p\\<0.001). In addition, there was significant improvement in pain rating at 3,6 and 12 months in the aquatic group compared to physical modalities (p\\<0.001). However, this study had no control group, increasing risk of bias and were unable to determine if benefits were from an active warm-up thus reducing validity. On the other hand, a study by Nemcic et al. \\[78\\] demonstrated no significant difference between an aquatic therapy group and land-based group after a 3 week programme in lumbar mobility and physical disability demonstrating either modality is modality is beneficial in managing LBP. Psychosocial Effects of Aquatic Therapy on Chronic Low Back Pain\\[edit \\| edit source\\] Introduction\\[edit \\| edit source\\] There are numerous psychosocial benefits from engaging in aquatic physiotherapy and recent research explains that all aquatic exercise is vital in promoting and managing mental health. Firstly, partaking in physical exercise can have many positive effects on quality of life due to the facilitation and promotion of social interaction. \\[79\\] \\[80\\] \\[81\\] On the other hand, psychosocial stressors and a sedentary lifestyle has been shown to reduce cellular functioning. Thus, promoting physical exercise is vital when treating and preventing depression \\[82\\] and other mental health disorders. Psychosocial benefits\\[edit \\| edit source\\] Stress relief Relaxation of muscles Water is associated with fun and relaxation Promotes body awareness Increases self-efficacy and confidence Group Hydrotherapy Session The warm water and physical properties of water (buoyancy and hydrostatic pressure) can provide stress relief allowing the muscles to relax, leading to tension relief and a reduction in muscle spasms, \\[83\\] promoting a less anxious state. Women partaking in aquatic physiotherapy report feeling comfortable and relaxed in the warm water. \\[84\\] Additionally, aquatic therapy can provide a sense of control and understanding of your own body due to the hydrostatic pressure promoting sensory receptors, allowing patients to take back control of their own movements, increasing self-efficacy and confidence. \\[85\\] Aquatic physiotherapy, depression and quality of life\\[edit \\| edit source\\] Silva \\[81\\] completed a study with 30 elderly participants to determine the effects of aquatic exercise on mental health. The participants were allocated into two groups (depression group and non-depression group) in which they completed an aquatic exercise programme for 12 weeks. They discovered that, in depressed elderly individuals, aquatic physiotherapy reduces depression and anxiety, improves activities of daily living, and reduces oxidative stress. A clinical trial of sedentary adults with CLBP by Beato, \\[86\\] examined the prognostic factors and disability change after a two-months intensive aquatic therapy programme compared to the control group. They discovered among others changes that quality of life improved. Suggesting an improvement in the patients psychosocially after an aquatic physiotherapy programme. Swim England Supports Aquatic Physiotherapy\\[edit \\| edit source\\] Swim England’s 2019 Value of Swimming report and the 2021 Decade of Decline report were both created to encourage and improve the awareness of swimming and aquatic therapy. Their overall aim is to prevent the closures of hydrotherapy pools. They report that this is because of the positive impact aquatic physiotherapy can have on one's physical and mental well-being. \\[87\\] The video below was made by Swim England, and shares Dominic's story, who has cerebral palsy and has been in a wheelchair most of his life. Dominic says \"I can walk by myself, swim by myself, just do everything in the water by myself, it really promotes my independence.” \\[87\\] “I think the main impact that aquatic physiotherapy has had on Dom is that it has both physical, physiological and psychosocial benefits.\" - Jacqueline Pattman. \\[87\\] Aquatic Physiotherapy Prescription\\[edit \\| edit source\\] As previous studies have shown, aquatic physiotherapy can be proven useful for reducing symptoms of CLBP. However, the question remains as to how frequent this intervention needs to take place for it to be effective in the short and long-term. Frequency Per Week\\[edit \\| edit source\\] There are a couple studies which look at the effect of different frequencies for this intervention. For example, Baena-Baeato et al.\\[88\\] compared the effect of completing aquatic therapy either 2x or 3x a week for CLBP patients over an 8-week period. This study included 54 participants who had CLBP for more than 12 weeks. They were split into a control group (education\/advice only), aquatic therapy 2x a week and then aquatic therapy 3x a week. Outcome measures of pain, disability, quality of life, body composition and health related fitness were used to determine the effects of the different frequencies. Results showed that both groups experienced significant improvements in back pain and disability compared to the control group. However, the 3x a week group showed significantly greater benefits with pain into flexion and disability levels compared to the 2x a week group. Both groups experienced significantly improved quality of life and health related parameters. There were no significant changes between the treatment groups and control in regard to body composition. Another study \\[89\\] investigated the optimal frequency of aquatic therapy for individuals with chronic musculoskeletal pain. This randomised control trial included 114 people with chronic musculoskeletal pain and had them participate in aquatic therapy either 2x or 3x a week for a year. Patients included experienced 1 of 3 musculoskeletal disorders: chronic lower back pain, chronic neck pain or osteoarthritis. Outcome measures included quality of life, disability index and WOMAC for OA patients. Measurements were taken at baseline, 8 weeks, 6 months and a year after the programme started. Results showed that there were no statistical differences between the two groups except the neck disability index at 8 weeks. There were improvements for all groups and all variables from baseline to a year. Length of Session and Content of Session\\[edit \\| edit source\\] Both studies \\[88\\] \\[89\\]included aquatic therapy sessions which were on average 60 minutes long. This is consistent with other studies which look generally at the effectiveness of aquatic therapy on CLBP. For example, in a systematic review, \\[53\\] 13 studies were reviewed, and the majority used interventions of aquatic therapy ranging from 45-60 minutes. Aquatic therapy sessions included warmups, muscle strength exercises, aerobic exercises and cool downs working on flexibility. This systematic review concluded that aquatic therapy improved pain, disability, and quality of life. What the Evidence Suggests\\[edit \\| edit source\\] As a result of these studies, it can be concluded that the optimal aquatic therapy prescription for CLBP patients should be 2x a week for 60-minute sessions. These sessions should include a mixture of aerobic and resistance exercises as well as a warmup and cool down. This knowledge has implications for rehabilitation, as it shows that 2x a week is often comparable to 3x a week of aquatic therapy for outcomes of CLBP. This can save resources and cost for patients and service providers without compromising the effects of the treatment. Conclusion\\[edit \\| edit source\\] CLBP is a highly common health issue within the population. It is a complex condition which has both biological and psychosocial components which need to be considered. As a result is important to investigate different treatment interventions on all of these components, measured by relevant outcome measures. Aquatic therapy has been proven to have extra benefits from land based training due to the unique properties of water, hence the decision to investigate the effect of this treatment on chronic low back pain. Literature has demonstrated multiple benefits of aquatic therapy in CLBP. These benefits include a decrease in pain levels and improvements in disability and function. Additionally, aquatic therapy has been shown to have psychological benefits which include improvements in self efficacy, confidence and anxiety\/depression for patients with CLBP. However, it is important to consider the limitations present within the studies when considering treatment options as currently there is not sufficient comprehensive research to suggest aquatic therapy is superior over land based exercise. Despite this, it is noteworthy that aquatic therapy can provide similar benefits to land based exercise with the addition of relaxation from the warm water. 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[International physical activity questionnaire: 12-country reliability and validity.](https:\/\/pubmed.ncbi.nlm.nih.gov\/12900694\/) Med Sci Sports Exerc. 2003 Aug 1;35(8):1381-95.\n\nRetrieved from \"<https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&oldid=332313>\"\n\n[Categories](https:\/\/www.physio-pedia.com\/Special:Categories \"Special:Categories\"):\n\n- [Nottingham University Spinal Rehabilitation Project](https:\/\/www.physio-pedia.com\/Category:Nottingham_University_Spinal_Rehabilitation_Project \"Category:Nottingham University Spinal Rehabilitation Project\")\n- [Lumbar Spine](https:\/\/www.physio-pedia.com\/Category:Lumbar_Spine \"Category:Lumbar Spine\")\n- [Lumbar Spine - Interventions](https:\/\/www.physio-pedia.com\/Category:Lumbar_Spine_-_Interventions \"Category:Lumbar Spine - Interventions\")\n- [Interventions](https:\/\/www.physio-pedia.com\/Category:Interventions \"Category:Interventions\")\n\nGet Top Tips Tuesday and The Latest Physiopedia updates\n\nIt's free, and you can unsubscribe any time. 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Acute is anything that persists for less than 6 weeks.\n2. Sub-acute is anything persisting between 6-12 weeks.\n3. [Chronic](https:\/\/www.physio-pedia.com\/Chronic_Low_Back_Pain) is anything persisting for 12 weeks or more.\n\nLBP is commonly described to be between the anatomical regions of the ribs and gluteal folds.[\\[4\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:1-4)\n\n## Anatomy\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=2 \"Edit section: Anatomy\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=2 \"Edit section: Anatomy\")\\]\nThe [lumbar spine](https:\/\/www.physio-pedia.com\/Lumbar_Anatomy \"Lumbar Anatomy\") comprises the lower end of the spinal column between the last [thoracic](https:\/\/www.physio-pedia.com\/Thoracic_Anatomy \"Thoracic Anatomy\") vertebra (T12) and the first [sacral vertebra](https:\/\/www.physio-pedia.com\/Sacrum \"Sacrum\") (S1). There is a total of five lumbar vertebrae (L1-L5) that are much larger compared to other regions within the vertebral column. These large [facets](https:\/\/www.physio-pedia.com\/Facet_Joints \"Facet Joints\") help support the upper body, as they absorb axial forces (against gravity) delivered from the head, neck, and trunk, and provide protection for the spinal cord from the canal that is formed. The lumbar spine allows for diverse types of trunk motion, including flexion, extension, rotation, and side bending, thus providing further reasons as to why the facets are much larger. Each lumbar segment consists of multiple components; vertebral body, transverse process, super articular process, super articular facet, intervertebral disc, vertebral forearm, the pedicle of the vertebral arch, lamina of the vertebral arch, and a spinous process.[\\[5\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-5)\n\nDue to the complex structure of spinal components, discs, intervertebral joints, muscles, and nerves, LBP can present with the same symptoms from different causes.\n\n## Epidemiology\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=3 \"Edit section: Epidemiology\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=3 \"Edit section: Epidemiology\")\\]\nLBP causes more disability than any other condition, affecting 1 in 10 people and becoming more common with increasing age, [\\[1\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1)with rates of 1%–6% in children aged 7–10 years, 18% in adolescents, and a peak prevalence ranging from 28% to 42% in people between 40 years and 69 years.[\\[6\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:3-6) The prevalence of LBP is thought to be increasing due to an increasing and aging population [\\[7\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-7) with estimates of life time prevalence being as high as 84% in the adult population. [\\[8\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-8)\n\n[![](https:\/\/www.physio-pedia.com\/images\/thumb\/6\/6f\/Picture_.png\/300px-Picture_.png)](https:\/\/www.physio-pedia.com\/File:Picture_.png)\n\nOne study that was carried out in 195 countries assessing the incidence, prevalence, and years lived with disability for 354 medical conditions found LBP to be the leading cause of worldwide productivity loss as measured in years, and the top cause of years lived with disability in 126 countries.[\\[6\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:3-6) In the United Kingdom (UK), it is estimated that LBP is responsible for 37% of all [chronic pain](https:\/\/www.physio-pedia.com\/Chronic_Pain_and_the_Brain \"Chronic Pain and the Brain\") in men and 44% in women and the total cost of LBP to the UK economy is reckoned to be over £12 billion per year. [\\[1\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1)\n\nRisk factors for LBP are age, sex, height, weight, sedentary lifestyle, depression, anxiety, insomnia, and smoking.[\\[10\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-10) Although muscle strain and imbalance, ligament sprain, and soft tissue damage account for almost all LBP, as it is [non-specific](https:\/\/www.physio-pedia.com\/Non_Specific_Low_Back_Pain), it often has no identifiable underlying condition or origin. [\\[11\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-11)\n\nOffice workers are usually required to sit for long hours working on a computer while spending most of their time in a sitting position. Approximately 34%- 51% of office workers experienced LBP in the preceding 12 months. Occupational groups exposed to '*poor postures'* while sitting for longer than half a day have a considerably increased risk of experiencing LBP. Subjects with LBP are likely to be in sustained postures and have large and infrequent spinal movements. Prolonged postural loading of the spine while sitting can reduce joint lubrication, fluid content of intervertebral discs, and increased stiffness. Additionally to this, prolonged muscle activation in static sitting may lead to localised muscle tension, muscle strains, muscle fatigue, and other soft-tissue damage, causing impairment of motor coordination and control as well as increased mechanical stress on ligaments and intervertebral discs.[\\[12\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-12)\n\nPrevalence of [walking in the United Kingdom](https:\/\/www.gov.uk\/government\/statistics\/walking-and-cycling-statistics-england-2020\/walking-and-cycling-statistics-england-2020):\n\n- People made an average of 236 walking trips and walked an average of 220 miles.\n- People on average have walked less than in 2019, following a fall in short walks.\n- People walked 7% farther in 2020 compared to 2019.\n\n- 67% of adults in England reported walking at least once a week.\n- 92% of local authorities had at least 60% of their adult population walking at least once a week.\n\nThe NHS provides a guide on ['walking for health'](https:\/\/www.nhs.uk\/live-well\/exercise\/running-and-aerobic-exercises\/walking-for-health\/), to help motivate the population and help them meet the recommended minimum moderate activity guidelines of 150 minutes.\n\n## Pedometer Driven Walking\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=4 \"Edit section: Pedometer Driven Walking\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=4 \"Edit section: Pedometer Driven Walking\")\\]\n[![](https:\/\/www.physio-pedia.com\/images\/f\/f9\/Pedometer._jp.jpg)](https:\/\/www.physio-pedia.com\/File:Pedometer._jp.jpg)\n\nExample of a pedometer\n\n[Pedometers](https:\/\/www.prevention.com\/fitness\/a20450112\/walking-tips-how-to-use-a-pedometer\/) are devices that work by counting the steps someone takes to estimate the distance they have traveled. [\\[13\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-13) Pedometers are usually worn at the hip (on the waistband of clothing) and in alignment with the patella although this may not be the case for all pedometers. There are also other ways of tracking steps - many people now have fitness trackers which are attached to the wrist and will also have the ability to count steps.\n\nInstructions will be included with pedometer devices, and as there are many [different types](https:\/\/www.prevention.com\/fitness\/a20450112\/walking-tips-how-to-use-a-pedometer\/) it is important to check these before usage to ensure that the pedometer is being used as accurately as possible. Some pedometers may also be more complex and do a little bit more than just counting steps such as showing calories burned, activity times, and memory logs.\n\nWhilst not a pedometer in the traditional sense, the [NHS](https:\/\/www.nhs.uk\/better-health\/get-active\/) (National Health Service) also has an application which is free to download called *'Active 10'* - this is designed to track walking and will indicate the total amount walked and how much of that was brisk walking. Within the app, there are also options to set goals, achieve milestones, and view progress over the weeks and months. So a pedometer is not the only option to keep a track of walking and daily activity - there are many more apps out there that will do the same thing\\!\n\nUsing an app as a pedometer or walking tracker does rely on the individual having a mobile phone and keeping it in their pocket to ensure it tracks all activity whereas a standard pedometer can be used by a wider number of people and may not be as complex.\n\n### Do Pedometers Increase Physical Activity?\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=5 \"Edit section: Do Pedometers Increase Physical Activity?\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=5 \"Edit section: Do Pedometers Increase Physical Activity?\")\\]\n[The NICE (National Institute for Health and Care Excellence) guidelines](https:\/\/www.nice.org.uk\/news\/article\/nice-publishes-updated-advice-on-treating-low-back-pain) on LBP and sciatica in over 16s - published in 2016 and last updated in 2020 - advises self-management and exercise as treatments. [\\[1\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1)A pedometer would be an easy way of giving someone a tool to help self-manage their activity levels, as long as this was an appropriate choice of exercise for the individual - those with LBP should be encouraged to continue with their regular activities as well. [\\[1\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1)\n\nA three-arm cluster, randomised control trial (RCT) conducted in 2016 with an eventual number of participants at 956 recruited from primary care settings, found that a pedometer-based walking intervention (regardless of whether there was nurse support) increased the step count and physical activity of generally inactive 45-75 year old at a 12 month follow up. [\\[14\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-14)A meta-analysis in 2009 of pedometer-based interventions for activity conducted in 2013 included 32 studies and found using pedometers to have a positive effect on physical activity and this was regardless of age or intervention length.[\\[15\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:13-15) The studies had varying interventions from keeping a daily log of steps, completing 10,000 steps, individualized goals, or a combination of strategies.[\\[15\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:13-15)\n\n### Do Pedometers Affect LBP?\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=6 \"Edit section: Do Pedometers Affect LBP?\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=6 \"Edit section: Do Pedometers Affect LBP?\")\\]\n#### Acute Low Back Pain (ALBP)\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=7 \"Edit section: Acute Low Back Pain (ALBP)\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=7 \"Edit section: Acute Low Back Pain (ALBP)\")\\]\nThere is arguably less research in relation to ALBP and the effects of using a pedometer. However, a study in 2015, focusing on those with ALBP of 48 hours or less looked at whether 'stay active' advice or 'adjusting activities to pain' had different effects. [\\[16\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:14-16) Participants were aged between 18 and 65 and all were provided with a pedometer to track daily steps with the instruction of wearing it at all times during waking hours, they found the pedometer an easily used intervention which increased physical activity, particularly in those with the advice to 'stay active'.[\\[16\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:14-16) This study shows that pedometers could have a useful place in treatment alongside other advice and management techniques for those with ALBP despite the study being over a short period of time, and the study size is relatively small.\n\n#### Chronic Low Back Pain (CLBP)\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=8 \"Edit section: Chronic Low Back Pain (CLBP)\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=8 \"Edit section: Chronic Low Back Pain (CLBP)\")\\]\nAs previously mentioned, [CLBP](https:\/\/www.physio-pedia.com\/Chronic_Low_Back_Pain \"Chronic Low Back Pain\") accounts for a significant amount of chronic pain in individuals of the UK, so interventions that aid in the treatment and management would be beneficial. A recent RCT published in 2021, looked at the effects of a pedometer-driven individualized walking plan compared to standardised care in increasing completion and adherence of physical activity in CLBP management.[\\[17\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:15-17)Whilst no significant difference was noted in disability or pain, there was an indication that using an individualised, guided pedometer program aided in adherence and participation of physical activity - although relevant measures such as step count were not taken from the standardised care group, so it is unclear if there were any increases in physical activity amongst them.[\\[17\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:15-17)\n\nA previous RCT from 2013, of an internet-based pedometer intervention, did find that in the short-term of 6 months back pain disability had decreased, but at 12 months there was no difference between the group with access to the internet support and the ones utilising the pedometer and standard management only.[\\[18\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-18)Again, this shows, that whilst pedometer-driven walking can have positive effects in physical activity and adherence, there may need to be further research to explore how positive outcomes can be gained in the long term.\n\nIt seems that pedometers can be a relatively cheap and accessibly form of intervention and management in individuals with LBP, and this can have greater positive impacts when included with support in one form or another.[\\[16\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:14-16)\n\n## Benefits of Walking on Low Back Pain\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=9 \"Edit section: Benefits of Walking on Low Back Pain\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=9 \"Edit section: Benefits of Walking on Low Back Pain\")\\]\n[![Walking dog.jpg](https:\/\/www.physio-pedia.com\/images\/thumb\/b\/b8\/Walking_dog.jpg\/300px-Walking_dog.jpg)](https:\/\/www.physio-pedia.com\/File:Walking_dog.jpg)\n\nThe lower back muscles play an important role in maintaining its stability and movement; two key aspects that are needed when walking. [\\[19\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:6-19) These [muscles](https:\/\/www.physio-pedia.com\/Muscle \"Muscle\") can become deconditioned in those with sedentary lifestyles, leading to weakness over time. This prolonged weakness can increase muscular fatigue, and injury, exaggerating the pain already being experienced. [\\[19\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:6-19) Reduced physical activity can also cause these muscles and the joints of the [lumbar spine](https:\/\/www.physio-pedia.com\/Lumbar_Anatomy \"Lumbar Anatomy\") to become stiff, which can increase the pressure on the lower back. [\\[20\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:7-20)\n\n[Walking has many positive impacts on the lower back](https:\/\/www.verywellfit.com\/walking-away-low-back-pain-3435479#toc-does-walking-really-prevent-low-back-pain), which can prevent or reduce these changes occurring in the following ways:\n\n1. Increased blood flow:\n   - Small blood vessels and capillaries in the lower back muscles can become constricted following decreased physical activity, [reducing the blood flow](https:\/\/www.spine-health.com\/blog\/2-reasons-why-walking-good-your-lower-back#vh_footnotes) to these muscles.\n   - Walking allows for more movement in these muscles, allowing these capillaries and blood vessels to open up again.\n   - This, in turn, increases the blood supply and nutrients to these muscles, improving muscular health and strength and aiding with the healing process. [\\[20\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:7-20)\n2. Stretch and contraction of muscles:\n   - The movement in the lower back during walking increases the stretch and contraction of the lower back muscles and those in the legs, buttocks, and core, allowing for more flexibility and mobility in this area.\n   - This flexibility [increases the overall range of motion](https:\/\/www.spine-health.com\/blog\/2-reasons-why-walking-good-your-lower-back#vh_footnotes) in the lower back, also improving the health and strength of the lower back muscles.\n\n[\\[21\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-21)\n\n## Treatment and Management\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=10 \"Edit section: Treatment and Management\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=10 \"Edit section: Treatment and Management\")\\]\n### Effect Of Walking On LBP\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=11 \"Edit section: Effect Of Walking On LBP\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=11 \"Edit section: Effect Of Walking On LBP\")\\]\nCurrent evidence supports the use of walking as a treatment option for LBP. A cross-sectional study from 2017 evaluating the relationship between walking and LBP, consisting of 5,982 adults, found that walking was associated with a reduced risk of LBP. [\\[22\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:9-22) The authors also found that the presence of LBP was proportionate to walking frequency, with those who walked more often having reduced LBP. These results are supported by those of a systematic review from 2019 evaluating the effects of walking on those with chronic LBP. [\\[23\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:10-23) Walking was found to be as effective as other non-pharmacological interventions on pain and disability in short-term (\\<3 months) and intermediate (3-12 months) follow-ups. These findings allowed for walking to be recommended for managing and treating LBP. [\\[23\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:10-23)\n\nThe effects of walking have been compared to the effects of exercise for LBP. A systematic review from 2019 comparing the two concluded that walking was as effective as exercise for improving pain, disability, quality of life, and fear-avoidance in those with chronic LBP. [\\[24\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:11-24) Much like the studies by Kim et al. [\\[22\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:9-22) and Sitthipornvorakul et al. [\\[23\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:10-23), Vanti et al. [\\[24\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:11-24) recommend the use of walking as a treatment and management option for LBP.\n\nInterestingly, a systematic review from 2022, found that people with LBP have altered gait patterns compared with healthy individuals. [\\[25\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:12-25) Those with LBP were found to walk slower, have reduced stride lengths, greater lumbar paraspinal activation, and reduced thorax\/pelvic coordination. [\\[25\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:12-25) However, the authors were unable to report if these changes were adaptive or maladaptive. Overall, these results indicate that gait re-education may be needed for those with LBP to gain the most benefits from walking.\n\nA systematic review in 2015 included seven randomised controlled trials involving 869 participants adults with chronic LBP. It compared walking to other non-pharmacological management methods such as usual care, specific strength exercises, medical exercise therapy, or supervised exercise classes. It suggested that walking is the same effective as other management methods while having a lower cost. [\\[26\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:18-26). It could be explained by its high accessibility, but does not require training, supervision, or specialised equipment. [\\[26\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:18-26)\n\nOther research supported that walking is as effective as conventional physiotherapy treatment such as lumbar stabilisation and muscle strengthening exercise. [\\[27\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:19-27)[\\[28\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:20-28) A randomised control trial included 48 participants comparing the effect of lumbar stabilisation exercise and walking exercise on LBP. It suggested both interventions significantly reduced LBP, and both interventions show similar results.[\\[28\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:20-28) Another randomised control trial compare strengthening exercise to a combined programme of strengthening exercise and walking exercise on chronic LBP. It suggested that both interventions were beneficial but combined exercise programme was more effective for reducing pain levels than the strength exercise. [\\[27\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:19-27)Another randomised control trial also supported 44 participants comparing conventional physiotherapy to a combination of conventional physiotherapy with walking exercise. It suggested that a combination of conventional physiotherapy with walking exercise is more effective to reduces pain and kinesiophobia, and improved function in patients with subacute and chronic non-specific LBP. [\\[29\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:21-29)\n\n### How to Use Walking as a Treatment for LBP\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=12 \"Edit section: How to Use Walking as a Treatment for LBP\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=12 \"Edit section: How to Use Walking as a Treatment for LBP\")\\]\n#### 1\\. Combine with conventional physiotherapy treatment\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=13 \"Edit section: 1. Combine with conventional physiotherapy treatment\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=13 \"Edit section: 1. Combine with conventional physiotherapy treatment\")\\]\nWalking is a low-cost intervention, and a combination of physiotherapy with walking is more effective than conventional physiotherapy alone. [\\[26\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:18-26)[\\[27\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:19-27)[\\[29\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:21-29) Walking exercise could be educated by physiotherapists alongside their exercise prescription. Recommendations support the use of exercise for at least 15 to 30 minutes most days for those with LBP. [\\[30\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-30) This can mean gradually building up walking distance and capacity to reduce the risk of injury and allow for the body to adapt to the changes.\n\n#### 2\\. Goal setting\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=14 \"Edit section: 2. Goal setting\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=14 \"Edit section: 2. Goal setting\")\\]\nThe use of a **pedometer** means that the patient is able to manage and keep track of their steps whilst walking. The patient might be advised to keep an **\"activity diary\"** which keeps track of a daily step count and the patient's step goal. This is achieved by calculating the patient's average step count in the first week of activity, and using this as a baseline when deciding a step goal for the second week. [\\[31\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:22-31) The use of an activity diary can also help establish the patients' baseline in the first week, which is important in informing their individual goals for rehabilitation. [\\[31\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:22-31)\n\nFor example, use pedometer\/tracking apps (like Active 10) to monitor and then set weekly targets (increase by a certain amount each week\/two weeks for example).\n\n#### 3\\. Postural Control\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=15 \"Edit section: 3. Postural Control\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=15 \"Edit section: 3. Postural Control\")\\]\nHaving the [correct walking posture](https:\/\/www.verywellfit.com\/how-to-walk-walking-posture-3432476) is important to allow for more comfortable walking, helping to reduce pain and discomfort. An optimal posture can be achieved using multiple strategies:\n\n1. Stand up straight:\n   - This can be achieved by making yourself as tall as possible, without leaning forwards or backward.\n   - Ensuring your chin is kept up and your eyes facing forwards allows for reduced strain on your neck and back.\n   - These together will allow for a better posture and improved balance. [\\[32\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-32)\n2. Keep shoulders back and relaxed:\n   - Relaxing your shoulders helps relieve tension and allows for a more neutral spine when walking.\n3. Engage core muscles and keep a neutral pelvis:\n   - engaging your core and keeping a neutral pelvis prevents arching of the spine and tilting of the pelvis, allowing for a more neutral spine and better posture. [\\[33\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-33)\n## Outcome measures\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=16 \"Edit section: Outcome measures\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=16 \"Edit section: Outcome measures\")\\]\nThere are a variety of outcome measures that might be used when advising walking as a management strategy for patients with LBP. These might look at:\n\n- Pain\n- Disability\n- Physical activity\n### Pain\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=17 \"Edit section: Pain\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=17 \"Edit section: Pain\")\\]\n#### Visual Analogue Scale (VAS)\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=18 \"Edit section: Visual Analogue Scale (VAS)\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=18 \"Edit section: Visual Analogue Scale (VAS)\")\\]\nThe **VAS ([Visual Analogue Scale](https:\/\/www.physio-pedia.com\/Visual_Analogue_Scale \"Visual Analogue Scale\"))** is one of the most common outcome measures for LBP. [\\[34\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-34)\n\nIt is an example of a subjective PROM (Patient Reported Outcome Measure), where the patient records their pain on a 100mm line- from \"no pain\" at the beginning to the \"worst pain imaginable\". Some types of VAS also use faces to represent pain from \"mild\", \"moderate\" to \"severe\", as shown below.\n\n[![](https:\/\/www.physio-pedia.com\/images\/thumb\/0\/02\/Visual_Analogue_Scale.jpg\/300px-Visual_Analogue_Scale.jpg)](https:\/\/www.physio-pedia.com\/File:Visual_Analogue_Scale.jpg)\n\nPrevious studies have found that the VAS is a \"reliable and valid\" outcome measure for use in a LBP population. [\\[36\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-36) It has also shown reliability in predicting disability due to LBP. [\\[37\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-37)\n\n### Disability\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=19 \"Edit section: Disability\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=19 \"Edit section: Disability\")\\]\n#### Roland-Morris Disability Questionnaire (RMDQ)\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=20 \"Edit section: Roland-Morris Disability Questionnaire (RMDQ)\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=20 \"Edit section: Roland-Morris Disability Questionnaire (RMDQ)\")\\]\nThe **[Roland-Morris Disability questionnaire (RMDQ)](https:\/\/www.physio-pedia.com\/Roland%E2%80%90Morris_Disability_Questionnaire \"Roland‐Morris Disability Questionnaire\")** is a commonly used PROM, designed to assess a patient's disability in relation to their LBP. It is a 24-item questionnaire that looks at physical functions that the patient feels have been affected, and a higher score represents a higher level of disability due to LBP. [\\[38\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-38)\n\n[![](https:\/\/www.physio-pedia.com\/images\/thumb\/0\/0d\/RMDQ_picture.webp\/390px-RMDQ_picture.webp.png)](https:\/\/www.physio-pedia.com\/File:RMDQ_picture.webp)\n\nAn example of the RMDQ [\\[39\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-39)\n\nA study from 2020 found that the RMDQ had good test-retest reliability and internal consistency reliability in capturing the \"everyday functional impact of low back pain\". [\\[40\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-40)\n\n#### Oswestry Disability Index (ODI)\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=21 \"Edit section: Oswestry Disability Index (ODI)\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=21 \"Edit section: Oswestry Disability Index (ODI)\")\\]\nThe **[Oswestry Disability Index (ODI)](https:\/\/www.physio-pedia.com\/Oswestry_Disability_Index \"Oswestry Disability Index\")** is also commonly used to assess functional disability in patients with LBP. [\\[41\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-41) It consists of 10 items which are detailed below, as well as the interpretation of the scores.\n\n[![](https:\/\/www.physio-pedia.com\/images\/thumb\/4\/41\/ODI_QUESTIONS.jpg\/390px-ODI_QUESTIONS.jpg)](https:\/\/www.physio-pedia.com\/File:ODI_QUESTIONS.jpg)\n\nOswestry Disability Index (ODI) [\\[42\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-42)\n\n[![](https:\/\/www.physio-pedia.com\/images\/thumb\/8\/85\/ODI_interpretation.png\/300px-ODI_interpretation.png)](https:\/\/www.physio-pedia.com\/File:ODI_interpretation.png)\n\nInterpretation of ODI scores [\\[43\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-43)\n\nThe ODI has been found to be a \"valid and reliable scale suitable for measurement of disability for low back pain\", and in particular showing high test-retest reliability. [\\[44\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-44)\n\nA study looked at comparing the ODI and the RMDQ to each other. The study found that the ODI appeared to be better at detecting changes in patients with more severe lower back pain, whereas the RMDQ seemed to have an advantage when measuring patients who had more mild disability.[\\[45\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-45)\n\n### Physical activity\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=22 \"Edit section: Physical activity\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=22 \"Edit section: Physical activity\")\\]\n#### International Physical Activity Questionnaire (IPAQ)\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=23 \"Edit section: International Physical Activity Questionnaire (IPAQ)\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=23 \"Edit section: International Physical Activity Questionnaire (IPAQ)\")\\]\nThe International Physical Activity Questionnaire (IPAQ) is formed of two different versions including the IPAQ short-form and the IPAQ long version. Both versions require the patient to recall their physical activity levels in the **past 7 days.** Based on these scores, they are placed in one of three categories: low activity levels, moderate activity levels, and high activity levels. [\\[46\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-46)\n\nThe **[IPAQ short-form](https:\/\/evaluationframework.sportengland.org\/media\/1084\/2015-ipaq-sf.pdf)** consists of 4 categories where the patient reports how much they participated in the following activities in the past 7 days:\n\n- Moderate activity\n- Vigorous activity\n- Time spent walking\n- Time spent sitting\n\nThe IPAQ short-form may be more beneficial for use in a clinical setting due to the shorter\/more accessible nature of the questionnaire for patients. [\\[47\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:2-47)\n\nThe **[IPAQ long version](https:\/\/www.physio-pedia.com\/images\/6\/6e\/International_Physical_Activity_Questionaire)** assesses physical activity across 5 domains:\n\n1. Job-related physical activity\n2. Transportation physical activity\n3. Housework, house maintenance, and caring for family\n4. Recreation, sport, and leisure time\n5. Time spent walking\n\nThe IPAQ long version is typically used in research studies or may be used if a more detailed picture of a patient's physical activity levels is preferred. [\\[47\\]](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:2-47)\n\nOverall, the [IPAQ](https:\/\/www.physio-pedia.com\/images\/6\/6e\/International_Physical_Activity_Questionaire) has been subject to extensive reliability and validity testing across 12 different countries (14 sites) from 2000 as an outcome measure for physical activity.\n\n## Suggestions for Future Clinical Research\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=24 \"Edit section: Suggestions for Future Clinical Research\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=24 \"Edit section: Suggestions for Future Clinical Research\")\\]\n- Based on the current literature, walking has been shown to be an effective management strategy for patients with LBP. However, more high-quality RCT’s need to be carried out using a  **variety of outcome measures,** including physical activity, to further investigate walking as an effective management strategy for LBP.\n\n- In order to strengthen the current evidence around this topic, further research could be carried out on how to ensure the **long term** **effects** of pedometer-based intervention. It would also be valuable to investigate whether added interventions might be necessary in aiding supportive positive outcomes long-term.\n- The current NICE guidelines for LBP and sciatica were published in 2016 and updated in 2020 for pharmacological interventions. However, the advice for “non-pharmacological interventions” last had an evidence review in **2016\\.** Therefore, it may be beneficial for a reassessment based on new evidence, in which guidelines around walking could be evaluated.\n## References\\[[edit](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=25 \"Edit section: References\") \\| [edit source](https:\/\/www.physio-pedia.com\/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=25 \"Edit section: References\")\\]\n1. ↑ [Jump up to: 1\\.0](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-0) [1\\.1](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-1) [1\\.2](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-2) [1\\.3](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-3) [1\\.4](https:\/\/www.physio-pedia.com\/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-4) De Campos TF. 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Meta Title	The Effects of Walking on Low Back Pain - Physiopedia
Meta Description	Low back pain (LBP) that is not associated with serious or potentially serious causes has been described in the literature as 'non-specific', 'mechanical', 'musculoskeletal', or 'simple' LBP.[1] Non-specific LBP is defined as LBP not attributable to a recognisable specific pathology (eg, infection, tumor, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome).[2]
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Boilerpipe Text	Introduction [ edit \| edit source ] Low back pain (LBP) that is not associated with serious or potentially serious causes has been described in the literature as ' non-specific ', 'mechanical', 'musculoskeletal', or 'simple' LBP. [1] Non-specific LBP is defined as LBP not attributable to a recognisable specific pathology (eg, infection, tumor, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome). [2] LBP between the rib cage and gluteal folds LBP can be further split into three categories; acute, sub-acute, and chronic . [3] Acute is anything that persists for less than 6 weeks. Sub-acute is anything persisting between 6-12 weeks. Chronic is anything persisting for 12 weeks or more. LBP is commonly described to be between the anatomical regions of the ribs and gluteal folds. [4] Anatomy [ edit \| edit source ] The lumbar spine comprises the lower end of the spinal column between the last thoracic vertebra (T12) and the first sacral vertebra (S1). There is a total of five lumbar vertebrae (L1-L5) that are much larger compared to other regions within the vertebral column. These large facets help support the upper body, as they absorb axial forces (against gravity) delivered from the head, neck, and trunk, and provide protection for the spinal cord from the canal that is formed. The lumbar spine allows for diverse types of trunk motion, including flexion, extension, rotation, and side bending, thus providing further reasons as to why the facets are much larger. Each lumbar segment consists of multiple components; vertebral body, transverse process, super articular process, super articular facet, intervertebral disc, vertebral forearm, the pedicle of the vertebral arch, lamina of the vertebral arch, and a spinous process. [5] Due to the complex structure of spinal components, discs, intervertebral joints, muscles, and nerves, LBP can present with the same symptoms from different causes. Epidemiology [ edit \| edit source ] LBP causes more disability than any other condition, affecting 1 in 10 people and becoming more common with increasing age, [1] with rates of 1%–6% in children aged 7–10 years, 18% in adolescents, and a peak prevalence ranging from 28% to 42% in people between 40 years and 69 years. [6] The prevalence of LBP is thought to be increasing due to an increasing and aging population [7] with estimates of life time prevalence being as high as 84% in the adult population. [8] One study that was carried out in 195 countries assessing the incidence, prevalence, and years lived with disability for 354 medical conditions found LBP to be the leading cause of worldwide productivity loss as measured in years, and the top cause of years lived with disability in 126 countries. [6] In the United Kingdom (UK), it is estimated that LBP is responsible for 37% of all chronic pain in men and 44% in women and the total cost of LBP to the UK economy is reckoned to be over £12 billion per year. [1] Risk factors for LBP are age, sex, height, weight, sedentary lifestyle, depression, anxiety, insomnia, and smoking. [10] Although muscle strain and imbalance, ligament sprain, and soft tissue damage account for almost all LBP, as it is non-specific , it often has no identifiable underlying condition or origin. [11] Office workers are usually required to sit for long hours working on a computer while spending most of their time in a sitting position. Approximately 34%- 51% of office workers experienced LBP in the preceding 12 months. Occupational groups exposed to ' poor postures' while sitting for longer than half a day have a considerably increased risk of experiencing LBP. Subjects with LBP are likely to be in sustained postures and have large and infrequent spinal movements. Prolonged postural loading of the spine while sitting can reduce joint lubrication, fluid content of intervertebral discs, and increased stiffness. Additionally to this, prolonged muscle activation in static sitting may lead to localised muscle tension, muscle strains, muscle fatigue, and other soft-tissue damage, causing impairment of motor coordination and control as well as increased mechanical stress on ligaments and intervertebral discs. [12] Prevalence of walking in the United Kingdom : People made an average of 236 walking trips and walked an average of 220 miles. People on average have walked less than in 2019, following a fall in short walks. People walked 7% farther in 2020 compared to 2019. 67% of adults in England reported walking at least once a week. 92% of local authorities had at least 60% of their adult population walking at least once a week. The NHS provides a guide on 'walking for health' , to help motivate the population and help them meet the recommended minimum moderate activity guidelines of 150 minutes. Pedometer Driven Walking [ edit \| edit source ] Example of a pedometer Pedometers are devices that work by counting the steps someone takes to estimate the distance they have traveled. [13] Pedometers are usually worn at the hip (on the waistband of clothing) and in alignment with the patella although this may not be the case for all pedometers. There are also other ways of tracking steps - many people now have fitness trackers which are attached to the wrist and will also have the ability to count steps. Instructions will be included with pedometer devices, and as there are many different types it is important to check these before usage to ensure that the pedometer is being used as accurately as possible. Some pedometers may also be more complex and do a little bit more than just counting steps such as showing calories burned, activity times, and memory logs. Whilst not a pedometer in the traditional sense, the NHS (National Health Service) also has an application which is free to download called 'Active 10' - this is designed to track walking and will indicate the total amount walked and how much of that was brisk walking. Within the app, there are also options to set goals, achieve milestones, and view progress over the weeks and months. So a pedometer is not the only option to keep a track of walking and daily activity - there are many more apps out there that will do the same thing! Using an app as a pedometer or walking tracker does rely on the individual having a mobile phone and keeping it in their pocket to ensure it tracks all activity whereas a standard pedometer can be used by a wider number of people and may not be as complex. Do Pedometers Increase Physical Activity? [ edit \| edit source ] The NICE (National Institute for Health and Care Excellence) guidelines on LBP and sciatica in over 16s - published in 2016 and last updated in 2020 - advises self-management and exercise as treatments. [1] A pedometer would be an easy way of giving someone a tool to help self-manage their activity levels, as long as this was an appropriate choice of exercise for the individual - those with LBP should be encouraged to continue with their regular activities as well. [1] A three-arm cluster, randomised control trial (RCT) conducted in 2016 with an eventual number of participants at 956 recruited from primary care settings, found that a pedometer-based walking intervention (regardless of whether there was nurse support) increased the step count and physical activity of generally inactive 45-75 year old at a 12 month follow up. [14] A meta-analysis in 2009 of pedometer-based interventions for activity conducted in 2013 included 32 studies and found using pedometers to have a positive effect on physical activity and this was regardless of age or intervention length. [15] The studies had varying interventions from keeping a daily log of steps, completing 10,000 steps, individualized goals, or a combination of strategies. [15] Do Pedometers Affect LBP? [ edit \| edit source ] Acute Low Back Pain (ALBP) [ edit \| edit source ] There is arguably less research in relation to ALBP and the effects of using a pedometer. However, a study in 2015, focusing on those with ALBP of 48 hours or less looked at whether 'stay active' advice or 'adjusting activities to pain' had different effects. [16] Participants were aged between 18 and 65 and all were provided with a pedometer to track daily steps with the instruction of wearing it at all times during waking hours, they found the pedometer an easily used intervention which increased physical activity, particularly in those with the advice to 'stay active'. [16] This study shows that pedometers could have a useful place in treatment alongside other advice and management techniques for those with ALBP despite the study being over a short period of time, and the study size is relatively small. Chronic Low Back Pain (CLBP) [ edit \| edit source ] As previously mentioned, CLBP accounts for a significant amount of chronic pain in individuals of the UK, so interventions that aid in the treatment and management would be beneficial. A recent RCT published in 2021, looked at the effects of a pedometer-driven individualized walking plan compared to standardised care in increasing completion and adherence of physical activity in CLBP management. [17] Whilst no significant difference was noted in disability or pain, there was an indication that using an individualised, guided pedometer program aided in adherence and participation of physical activity - although relevant measures such as step count were not taken from the standardised care group, so it is unclear if there were any increases in physical activity amongst them. [17] A previous RCT from 2013, of an internet-based pedometer intervention, did find that in the short-term of 6 months back pain disability had decreased, but at 12 months there was no difference between the group with access to the internet support and the ones utilising the pedometer and standard management only. [18] Again, this shows, that whilst pedometer-driven walking can have positive effects in physical activity and adherence, there may need to be further research to explore how positive outcomes can be gained in the long term. It seems that pedometers can be a relatively cheap and accessibly form of intervention and management in individuals with LBP, and this can have greater positive impacts when included with support in one form or another. [16] Benefits of Walking on Low Back Pain [ edit \| edit source ] The lower back muscles play an important role in maintaining its stability and movement; two key aspects that are needed when walking. [19] These muscles can become deconditioned in those with sedentary lifestyles, leading to weakness over time. This prolonged weakness can increase muscular fatigue, and injury, exaggerating the pain already being experienced. [19] Reduced physical activity can also cause these muscles and the joints of the lumbar spine to become stiff, which can increase the pressure on the lower back. [20] Walking has many positive impacts on the lower back , which can prevent or reduce these changes occurring in the following ways: Increased blood flow: Small blood vessels and capillaries in the lower back muscles can become constricted following decreased physical activity, reducing the blood flow to these muscles. Walking allows for more movement in these muscles, allowing these capillaries and blood vessels to open up again. This, in turn, increases the blood supply and nutrients to these muscles, improving muscular health and strength and aiding with the healing process. [20] Stretch and contraction of muscles: The movement in the lower back during walking increases the stretch and contraction of the lower back muscles and those in the legs, buttocks, and core, allowing for more flexibility and mobility in this area. This flexibility increases the overall range of motion in the lower back, also improving the health and strength of the lower back muscles. [21] Treatment and Management [ edit \| edit source ] Effect Of Walking On LBP [ edit \| edit source ] Current evidence supports the use of walking as a treatment option for LBP. A cross-sectional study from 2017 evaluating the relationship between walking and LBP, consisting of 5,982 adults, found that walking was associated with a reduced risk of LBP. [22] The authors also found that the presence of LBP was proportionate to walking frequency, with those who walked more often having reduced LBP. These results are supported by those of a systematic review from 2019 evaluating the effects of walking on those with chronic LBP. [23] Walking was found to be as effective as other non-pharmacological interventions on pain and disability in short-term (<3 months) and intermediate (3-12 months) follow-ups. These findings allowed for walking to be recommended for managing and treating LBP. [23] The effects of walking have been compared to the effects of exercise for LBP. A systematic review from 2019 comparing the two concluded that walking was as effective as exercise for improving pain, disability, quality of life, and fear-avoidance in those with chronic LBP. [24] Much like the studies by Kim et al. [22] and Sitthipornvorakul et al. [23] , Vanti et al. [24] recommend the use of walking as a treatment and management option for LBP. Interestingly, a systematic review from 2022, found that people with LBP have altered gait patterns compared with healthy individuals. [25] Those with LBP were found to walk slower, have reduced stride lengths, greater lumbar paraspinal activation, and reduced thorax/pelvic coordination. [25] However, the authors were unable to report if these changes were adaptive or maladaptive. Overall, these results indicate that gait re-education may be needed for those with LBP to gain the most benefits from walking. A systematic review in 2015 included seven randomised controlled trials involving 869 participants adults with chronic LBP. It compared walking to other non-pharmacological management methods such as usual care, specific strength exercises, medical exercise therapy, or supervised exercise classes. It suggested that walking is the same effective as other management methods while having a lower cost. [26] . It could be explained by its high accessibility, but does not require training, supervision, or specialised equipment. [26] Other research supported that walking is as effective as conventional physiotherapy treatment such as lumbar stabilisation and muscle strengthening exercise. [27] [28] A randomised control trial included 48 participants comparing the effect of lumbar stabilisation exercise and walking exercise on LBP. It suggested both interventions significantly reduced LBP, and both interventions show similar results. [28] Another randomised control trial compare strengthening exercise to a combined programme of strengthening exercise and walking exercise on chronic LBP. It suggested that both interventions were beneficial but combined exercise programme was more effective for reducing pain levels than the strength exercise. [27] Another randomised control trial also supported 44 participants comparing conventional physiotherapy to a combination of conventional physiotherapy with walking exercise. It suggested that a combination of conventional physiotherapy with walking exercise is more effective to reduces pain and kinesiophobia, and improved function in patients with subacute and chronic non-specific LBP. [29] How to Use Walking as a Treatment for LBP [ edit \| edit source ] 1. Combine with conventional physiotherapy treatment [ edit \| edit source ] Walking is a low-cost intervention, and a combination of physiotherapy with walking is more effective than conventional physiotherapy alone. [26] [27] [29] Walking exercise could be educated by physiotherapists alongside their exercise prescription. Recommendations support the use of exercise for at least 15 to 30 minutes most days for those with LBP. [30] This can mean gradually building up walking distance and capacity to reduce the risk of injury and allow for the body to adapt to the changes. 2. Goal setting [ edit \| edit source ] The use of a pedometer means that the patient is able to manage and keep track of their steps whilst walking. The patient might be advised to keep an "activity diary" which keeps track of a daily step count and the patient's step goal. This is achieved by calculating the patient's average step count in the first week of activity, and using this as a baseline when deciding a step goal for the second week. [31] The use of an activity diary can also help establish the patients' baseline in the first week, which is important in informing their individual goals for rehabilitation. [31] For example, use pedometer/tracking apps (like Active 10) to monitor and then set weekly targets (increase by a certain amount each week/two weeks for example). 3. Postural Control [ edit \| edit source ] Having the correct walking posture is important to allow for more comfortable walking, helping to reduce pain and discomfort. An optimal posture can be achieved using multiple strategies: Stand up straight: This can be achieved by making yourself as tall as possible, without leaning forwards or backward. Ensuring your chin is kept up and your eyes facing forwards allows for reduced strain on your neck and back. These together will allow for a better posture and improved balance. [32] Keep shoulders back and relaxed: Relaxing your shoulders helps relieve tension and allows for a more neutral spine when walking. Engage core muscles and keep a neutral pelvis: engaging your core and keeping a neutral pelvis prevents arching of the spine and tilting of the pelvis, allowing for a more neutral spine and better posture. [33] Outcome measures [ edit \| edit source ] There are a variety of outcome measures that might be used when advising walking as a management strategy for patients with LBP. These might look at: Pain Disability Physical activity Pain [ edit \| edit source ] Visual Analogue Scale (VAS) [ edit \| edit source ] The VAS ( Visual Analogue Scale ) is one of the most common outcome measures for LBP. [34] It is an example of a subjective PROM (Patient Reported Outcome Measure), where the patient records their pain on a 100mm line- from "no pain" at the beginning to the "worst pain imaginable". Some types of VAS also use faces to represent pain from "mild", "moderate" to "severe", as shown below. Previous studies have found that the VAS is a "reliable and valid" outcome measure for use in a LBP population. [36] It has also shown reliability in predicting disability due to LBP. [37] Disability [ edit \| edit source ] Roland-Morris Disability Questionnaire (RMDQ) [ edit \| edit source ] The Roland-Morris Disability questionnaire (RMDQ) is a commonly used PROM, designed to assess a patient's disability in relation to their LBP. It is a 24-item questionnaire that looks at physical functions that the patient feels have been affected, and a higher score represents a higher level of disability due to LBP. [38] An example of the RMDQ [39] A study from 2020 found that the RMDQ had good test-retest reliability and internal consistency reliability in capturing the "everyday functional impact of low back pain". [40] Oswestry Disability Index (ODI) [ edit \| edit source ] The Oswestry Disability Index (ODI) is also commonly used to assess functional disability in patients with LBP. [41] It consists of 10 items which are detailed below, as well as the interpretation of the scores. Oswestry Disability Index (ODI) [42] Interpretation of ODI scores [43] The ODI has been found to be a "valid and reliable scale suitable for measurement of disability for low back pain", and in particular showing high test-retest reliability. [44] A study looked at comparing the ODI and the RMDQ to each other. The study found that the ODI appeared to be better at detecting changes in patients with more severe lower back pain, whereas the RMDQ seemed to have an advantage when measuring patients who had more mild disability. [45] Physical activity [ edit \| edit source ] International Physical Activity Questionnaire (IPAQ) [ edit \| edit source ] The International Physical Activity Questionnaire (IPAQ) is formed of two different versions including the IPAQ short-form and the IPAQ long version. Both versions require the patient to recall their physical activity levels in the past 7 days. Based on these scores, they are placed in one of three categories: low activity levels, moderate activity levels, and high activity levels. [46] The IPAQ short-form consists of 4 categories where the patient reports how much they participated in the following activities in the past 7 days: Moderate activity Vigorous activity Time spent walking Time spent sitting The IPAQ short-form may be more beneficial for use in a clinical setting due to the shorter/more accessible nature of the questionnaire for patients. [47] The IPAQ long version assesses physical activity across 5 domains: Job-related physical activity Transportation physical activity Housework, house maintenance, and caring for family Recreation, sport, and leisure time Time spent walking The IPAQ long version is typically used in research studies or may be used if a more detailed picture of a patient's physical activity levels is preferred. [47] Overall, the IPAQ has been subject to extensive reliability and validity testing across 12 different countries (14 sites) from 2000 as an outcome measure for physical activity. Suggestions for Future Clinical Research [ edit \| edit source ] Based on the current literature, walking has been shown to be an effective management strategy for patients with LBP. However, more high-quality RCT’s need to be carried out using a variety of outcome measures, including physical activity, to further investigate walking as an effective management strategy for LBP. In order to strengthen the current evidence around this topic, further research could be carried out on how to ensure the long term effects of pedometer-based intervention. It would also be valuable to investigate whether added interventions might be necessary in aiding supportive positive outcomes long-term. The current NICE guidelines for LBP and sciatica were published in 2016 and updated in 2020 for pharmacological interventions. However, the advice for “non-pharmacological interventions” last had an evidence review in 2016. Therefore, it may be beneficial for a reassessment based on new evidence, in which guidelines around walking could be evaluated. References [ edit \| edit source ] ↑ Jump up to: 1.0 1.1 1.2 1.3 1.4 De Campos TF. Low back pain and sciatica in over 16s: assessment and management NICE Guideline [NG59] . J Physiother. 2017 Apr 1;63(2):120. ↑ Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012 Feb 4;379(9814):482-91. ↑ Burton AK, Balagué F, Cardon G, Eriksen HR, Henrotin Y, Lahad A, Leclerc A, Müller G, Van Der Beek AJ, COST B13 Working Group on Guidelines for Prevention in Low Back Pain. European guidelines for prevention in low back pain: November 2004. European Spine Journal. 2006 Mar;15(Suppl 2):s136. ↑ Firestein GS, Budd RC, Gabriel SE, McInnes IB, O'Dell JR. Kelley and Firestein's textbook of rheumatology. Elsevier Health Sciences; 2016 Jun 21. ↑ Sassack B, Carrier J. Anatomy, Back, Lumbar Spine. [online] StatPerals [Intenet] 2022; August 25. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557616/ [accessed 25/4/2022] ↑ Jump up to: 6.0 6.1 Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain . Lancet. 2021 Jul 3;398(10294):78-92. ↑ Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, Croft P, Hartvigsen J, Cherkin D, Foster NE, Maher CG. Low back pain: a call for action. Lancet. 2018 Jun 9;391(10137):2384-8. ↑ Casiano VE, Sarwan G, Dydyk AM, Varacallo M. Back Pain. StatPearls [Internet]. 2022 Feb 22. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538173/ [accessed 25/4/2023] ↑ Wu A, March L, Zheng X, Huang J, Wang X, Zhao J, Blyth F, Smith E, Buchbinder R, Hoy D. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med 2020; 8(6): 299. ↑ Sharp C. Musculoskeletal conditions and disorders in P.L. Jacobs (Ed) NSCA’s essentials of training special populations. Champaign, IL: Human Kinetics. 2018 ↑ Soloman J. Low back pain. In: J.S. Skinner, C.X. Bryant, S. Merrill, & D.J. Green (Eds), American Council on Exercise medical exercise specialist manual. San Diego, CA: American Council on Exercise.2015 ↑ Waongenngarm P, Areerak K, Janwantanakul P. The effects of breaks on low back pain, discomfort, and work productivity in office workers: A systematic review of randomized and non-randomized controlled trials. Applied ergonomics. 2018 Apr 1;68:230-9. ↑ Tudor-Locke C, Lutes L. Why do pedometers work?: a reflection upon the factors related to successfully increasing physical activity. Sports Med. 2009;39(12):981-93. ↑ Harris T, Kerry SM, Limb ES, Victor CR, Iliffe S, Ussher M, Whincup PH, Ekelund U, Fox-Rushby J, Furness C, Anokye N. Effect of a Primary Care Walking Intervention with and without Nurse Support on Physical Activity Levels in 45-to 75-Year-Olds: The P pedometer A and C consultation E valuation (PACE-UP) Cluster Randomised Clinical Trial. PLoS Medicine. 2017 Jan 3;14(1):e1002210. ↑ Jump up to: 15.0 15.1 Kang M, Marshall SJ, Barreira TV, Lee JO. Effect of pedometer-based physical activity interventions: a meta-analysis. Res Q Exerc Sport. 2009 Sep 1;80(3):648-55. ↑ Jump up to: 16.0 16.1 16.2 Olaya-Contreras P, Styf J, Arvidsson D, Frennered K, Hansson T. The effect of the stay active advice on physical activity and on the course of acute severe low back pain. BMC Sports Sci Med Rehabil. 2015 Dec;7(1):1-9. ↑ Jump up to: 17.0 17.1 Lang AE, Hendrick PA, Clay L, Mondal P, Trask CM, Bath B, Penz ED, Stewart SA, Baxter GD, Hurley DA, McDonough SM. A randomized controlled trial investigating the effects of an individualized pedometer-driven walking program on chronic low back pain. BMC Musculoskelet Disord. 2021 Dec;22(1):1-4. ↑ Krein SL, Kadri R, Hughes M, Kerr EA, Piette JD, Holleman R, Kim HM, Richardson CR. Pedometer-based internet-mediated intervention for adults with chronic low back pain: randomized controlled trial. JMIR. 2013 Aug 22;15(8):e2605. ↑ Jump up to: 19.0 19.1 Valdivieso P, Franchi MV, Gerber C, Flück M. Does a better perfusion of deconditioned muscle tissue release chronic Low Back pain? . Front Med. 2018 Mar 20;5:77. ↑ Jump up to: 20.0 20.1 Gordon R, Bloxham S. A systematic review of the effects of exercise and physical activity on non-specific chronic low back pain. Healthcare 2016 Apr 25; 4(2):22. ↑ Tillotson C. How to walk correctly and fix your lower back pain. Take the Five Easy Steps. Available from: http://www.youtube.com/watch?v=B9jt4d_828g [accessed 26/4/2023] ↑ Jump up to: 22.0 22.1 Kim H, Min TJ, Kang SH, Kim DK, Seo KM, Lee SY. Association between walking and low back pain in the Korean population: a cross-sectional study. Ann Rehabil Med. 2017 Oct 31;41(5):786-92. ↑ Jump up to: 23.0 23.1 23.2 Sitthipornvorakul E, Klinsophon T, Sihawong R, Janwantanakul P. The effects of walking intervention in patients with chronic low back pain: A meta-analysis of randomized controlled trials. Musculoskelet Sci Pract. 2018 Apr 1;34:38-46. ↑ Jump up to: 24.0 24.1 Vanti C, Andreatta S, Borghi S, Guccione A, Pillastrini P, Bertozzi L. The effectiveness of walking versus exercise on pain and function in chronic low back pain: a systematic review and meta-analysis of randomized trials. Disabil Rehabil. 2019 Mar 13;41(6):622-32. ↑ Jump up to: 25.0 25.1 Smith J, Stabbert H, Bagwell J, Teng H, Wade V, Lee S. Do people with low back pain walk differently? A systematic review and meta-analysis. J Sport Health Sci. 2022 Jul;11(4):450-465. ↑ Jump up to: 26.0 26.1 26.2 Lawford BJ, Walters J, Ferrar K. Does walking improve disability status, function, or quality of life in adults with chronic low back pain? A systematic review. Clin Rehabil. 2016 Jun;30(6):523-36. ↑ Jump up to: 27.0 27.1 27.2 Lee JS, Kang SJ. The effects of strength exercise and walking on lumbar function, pain level, and body composition in chronic back pain patients. J Exerc Rehabil. 2016 Oct;12(5):463-70. ↑ Jump up to: 28.0 28.1 Suh JH, Kim H, Jung GP, Ko JY, Ryu JS. The effect of lumbar stabilization and walking exercises on chronic low back pain: A randomized controlled trial. Medicine (Baltimore). 2019 Jun;98(26):e16173. ↑ Jump up to: 29.0 29.1 Yilmaz Yelvar GD, Çırak Y, Dalkılınç M, Parlak Demir Y, Guner Z, Boydak A. Is physiotherapy integrated virtual walking effective on pain, function, and kinesiophobia in patients with non-specific low-back pain? Randomised controlled trial. Eur Spine J. 2017 Feb;26(2):538-45. ↑ Norris MK, Fox FS, Lee C, Wang E, Green K, Yan H, Dieli-Conwright CM. Narrowing the gap for minority cancer survivors: exercise oncology in the past, present, and future. Journal of Clinical Exercise Physiology. 2020 Dec;9(4):155-70. ↑ Jump up to: 31.0 31.1 Nicolson PJ, Bennell KL, Dobson FL, Van Ginckel A, Holden MA, Hinman RS. Interventions to increase adherence to therapeutic exercise in older adults with low back pain and/or hip/knee osteoarthritis: a systematic review and meta-analysis. Br J Sports Med. 2017 May 1;51(10):791-9. ↑ Pickle NT, Grabowski AM, Auyang AG, Silverman AK. The functional roles of muscles during sloped walking. J Biomech. 2016 Oct 3;49(14):3244-51. ↑ Jung J, Yu J, Kang H. Differences in trunk muscle activities and ratios between unstable supine and prone bridging exercises in individuals with low back pain . Journal of Physical Therapy Science. 2012;24(9):889-92. ↑ Chiarotto A, Maxwell LJ, Ostelo RW, Boers M, Tugwell P, Terwee CB. Measurement properties of visual analogue scale, numeric rating scale, and pain severity subscale of the brief pain inventory in patients with low back pain: a systematic review. J Pain. 2019 Mar 1;20(3):245-63. ↑ WeCapable.com. Visual Analogue Scale for pain (VAS): Scoring pain on 100mm line. Disability information. 2022. Available from: https://wecapable.com/vas-pain-scale-100mm-line/ [accessed 27/5/2023] ↑ Olaogun MO, Adedoyin RA, Ikem IC, Anifaloba OR. Reliability of rating low back pain with a visual analog scale and a semantic differential scale. Physiotherapy Theory and Practice. 2004 Jan 1;20(2):135-42. ↑ Shafshak TS, Elnemr R. The visual analog scale versus numerical rating scale in measuring pain severity and predicting disability in low back pain. J Clin Rheumatol. 2021 Oct 1;27(7):282-5. ↑ Chiarotto A, Maxwell LJ, Terwee CB, Wells GA, Tugwell P, Ostelo RW. Roland-Morris Disability Questionnaire and Oswestry Disability Index: which has better measurement properties for measuring physical functioning in nonspecific low back pain? Systematic review and meta-analysis . Phys Ther. 2016 Oct 1;96(10):1620-37. ↑ PrimePhysio. Roland-Morris Disability Questionnaire. Orthopaedic manual therapy certificate. Available from: https://www.primephysio.com/forum/_omtc/roland-morris-disability-questionnaire-rmdq [accessed 27/5/ 2023] ↑ Burbridge C, Randall J, Abraham L, Bush E. Measuring the impact of chronic low back pain on everyday functioning: content validity of the Roland Morris disability questionnaire. J Patient Rep Outcomes. 2020 Dec;4(1):1-5. ↑ Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976). 2000 Nov 15;25(22):2940-52 ↑ Haegg O. Oswestry Disability Index. Encyclopedia of Pain. 2013 Edition. Available from: https://link.springer.com/referenceworkentry/10.1007/978-3-642-28753-4_3021#howtocite [accessed 27/5/2023] ↑ Jalil N, Sulaiman Z, Awang M, Omar M. Retrospective Review of Outcomes of a Multimodal Chronic Pain Service in a Major Teaching Hospital: A Preliminary Experience in Universiti Sains Malaysia. Malays J Med Sci. 2009; 16(4): 55-65. ↑ Lee CP, Fu TS, Liu CY, Hung CI. Psychometric evaluation of the Oswestry Disability Index in patients with chronic low back pain: factor and Mokken analyses. Health Qual Life Outcomes. 2017 Dec;15(1):1-7. ↑ Fairbank J, Pynsent P. The Oswestry Disability Index . Spine 2000; 25(22):2940-53. ↑ Forde C. Scoring the International Physical activity questionnaire (IPAQ). Exercise prescription for the prevention and treatment of disease, University of Dublin 2018; 3. Available from: https://ugc.futurelearn.com/uploads/files/bc/c5/bcc53b14-ec1e-4d90-88e3-1568682f32ae/IPAQ_PDF.pdf [accessed 27/5/2023] ↑ Jump up to: 47.0 47.1 Craig C, Marshall A, Sjöström M, Bauman A, Booth M, Ainsworth B, Pratt M, Ekelund U, Yngve A, Sallis J, Oja P. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003 Aug 1;35(8):1381-95.
Markdown	![Physiopedia logo](https://www.physio-pedia.com/skins/PhysiopediaSkin/resources/images/PP-logo-horizontal.png) Toggle navigation - [pPhysiopedia](https://www.physio-pedia.com/home "Physiopedia") - [pPhysiopedia](https://www.physio-pedia.com/home "Physiopedia") - [About](https://www.physio-pedia.com/Physiopedia:About) - [News](https://members.physio-pedia.com/plus-news/) - [Contribute](https://www.physio-pedia.com/Contribute) - [Courses](https://members.physio-pedia.com/learn/?utm_source=physiopedia&utm_medium=top_nav_courses&utm_campaign=ongoing_internal) - [PAI](https://members.physio-pedia.com/physiopedia-ai-assistant/?utm_source=physiopedia&utm_medium=top_nav_pai&utm_campaign=ongoing_internal) - [Pages](https://www.physio-pedia.com/Articles) - [Shop](https://shop.physio-pedia.com/) - [Contact](https://members.physio-pedia.com/pp-contact-us/) - [Login](https://www.physio-pedia.com/index.php?title=Special:UserLogin&returnto=The+Effects+of+Walking+on+Low+Back+Pain) [pPhysiopedia](https://www.physio-pedia.com/home "Physiopedia") - [About](https://www.physio-pedia.com/Physiopedia:About) - [News](https://members.physio-pedia.com/plus-news/) - [Contribute](https://www.physio-pedia.com/Contribute) - [Courses](https://members.physio-pedia.com/learn/?utm_source=physiopedia&utm_medium=mobile_nav_courses&utm_campaign=ongoing_internal) - [PAI](https://members.physio-pedia.com/physiopedia-ai-assistant/?utm_source=physiopedia&utm_medium=mobile_nav_pai&utm_campaign=ongoing_internal) - [Pages](https://www.physio-pedia.com/Articles) - [Shop](https://shop.physio-pedia.com/) - [Contact](https://members.physio-pedia.com/pp-contact-us/) [p](https://www.physio-pedia.com/home "Physiopedia") [\+](https://members.physio-pedia.com/?utm_source=physiopedia&utm_medium=mobile_logo&utm_campaign=ongoing_internal "Plus") - [Contents](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#contents) - [Editors](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#editors) - [Categories](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#categories) - [Cite](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#citation) ## Contents - [1 Introduction](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Introduction) - [2 Anatomy](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Anatomy) - [3 Epidemiology](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Epidemiology) - [4 Pedometer Driven Walking](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Pedometer_Driven_Walking) - [4\.1 Do Pedometers Increase Physical Activity?](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Do_Pedometers_Increase_Physical_Activity?) - [4\.2 Do Pedometers Affect LBP?](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Do_Pedometers_Affect_LBP?) - [4\.2.1 Acute Low Back Pain (ALBP)](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Acute_Low_Back_Pain_\(ALBP\)) - [4\.2.2 Chronic Low Back Pain (CLBP)](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Chronic_Low_Back_Pain_\(CLBP\)) - [5 Benefits of Walking on Low Back Pain](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Benefits_of_Walking_on_Low_Back_Pain) - [6 Treatment and Management](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Treatment_and_Management) - [6\.1 Effect Of Walking On LBP](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Effect_Of_Walking_On_LBP) - [6\.2 How to Use Walking as a Treatment for LBP](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#How_to_Use_Walking_as_a_Treatment_for_LBP) - [6\.2.1 1\. Combine with conventional physiotherapy treatment](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#1._Combine_with_conventional_physiotherapy_treatment) - [6\.2.2 2\. Goal setting](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#2._Goal_setting) - [6\.2.3 3\. Postural Control](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#3._Postural_Control) - [7 Outcome measures](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Outcome_measures) - [7\.1 Pain](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Pain) - [7\.1.1 Visual Analogue Scale (VAS)](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Visual_Analogue_Scale_\(VAS\)) - [7\.2 Disability](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Disability) - [7\.2.1 Roland-Morris Disability Questionnaire (RMDQ)](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Roland-Morris_Disability_Questionnaire_\(RMDQ\)) - [7\.2.2 Oswestry Disability Index (ODI)](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Oswestry_Disability_Index_\(ODI\)) - [7\.3 Physical activity](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Physical_activity) - [7\.3.1 International Physical Activity Questionnaire (IPAQ)](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#International_Physical_Activity_Questionnaire_\(IPAQ\)) - [8 Suggestions for Future Clinical Research](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Suggestions_for_Future_Clinical_Research) - [9 References](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#References) Original Editor \- [Toby Stowe](https://www.physio-pedia.com/User:Toby_Stowe "User:Toby Stowe") as part of the [Nottingham University Spinal Rehabilitation Project](https://www.physio-pedia.com/Nottingham_University_Spinal_Rehabilitation_Project "Nottingham University Spinal Rehabilitation Project") Top Contributors - [Toby Stowe](https://www.physio-pedia.com/User:Toby_Stowe "User:Toby Stowe") , [Angeliki Chorti](https://www.physio-pedia.com/User:Angeliki_Chorti "User:Angeliki Chorti") , [Khloud Shreif](https://www.physio-pedia.com/User:Khloud_Shreif "User:Khloud Shreif") and [Cindy John-Chu](https://www.physio-pedia.com/User:Cindy_John-Chu "User:Cindy John-Chu") When refering to evidence in academic writing, you should always try to reference the primary (original) source. 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[Cite article](https://www.physio-pedia.com/index.php?title=Special%3ACiteThisPage&wpFormIdentifier=titleform&page=The%20Effects%20of%20Walking%20on%20Low%20Back%20Pain) # The Effects of Walking on Low Back Pain Jump to:[navigation](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#mw-navigation), [search](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#p-search) Original Editor \- [Toby Stowe](https://www.physio-pedia.com/User:Toby_Stowe "User:Toby Stowe") as part of the [Nottingham University Spinal Rehabilitation Project](https://www.physio-pedia.com/Nottingham_University_Spinal_Rehabilitation_Project "Nottingham University Spinal Rehabilitation Project") Top Contributors - [Toby Stowe](https://www.physio-pedia.com/User:Toby_Stowe "User:Toby Stowe") , [Angeliki Chorti](https://www.physio-pedia.com/User:Angeliki_Chorti "User:Angeliki Chorti") , [Khloud Shreif](https://www.physio-pedia.com/User:Khloud_Shreif "User:Khloud Shreif") and [Cindy John-Chu](https://www.physio-pedia.com/User:Cindy_John-Chu "User:Cindy John-Chu") ## Contents - [1 Introduction](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Introduction) - [2 Anatomy](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Anatomy) - [3 Epidemiology](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Epidemiology) - [4 Pedometer Driven Walking](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Pedometer_Driven_Walking) - [4\.1 Do Pedometers Increase Physical Activity?](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Do_Pedometers_Increase_Physical_Activity?) - [4\.2 Do Pedometers Affect LBP?](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Do_Pedometers_Affect_LBP?) - [4\.2.1 Acute Low Back Pain (ALBP)](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Acute_Low_Back_Pain_\(ALBP\)) - [4\.2.2 Chronic Low Back Pain (CLBP)](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Chronic_Low_Back_Pain_\(CLBP\)) - [5 Benefits of Walking on Low Back Pain](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Benefits_of_Walking_on_Low_Back_Pain) - [6 Treatment and Management](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Treatment_and_Management) - [6\.1 Effect Of Walking On LBP](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Effect_Of_Walking_On_LBP) - [6\.2 How to Use Walking as a Treatment for LBP](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#How_to_Use_Walking_as_a_Treatment_for_LBP) - [6\.2.1 1\. Combine with conventional physiotherapy treatment](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#1._Combine_with_conventional_physiotherapy_treatment) - [6\.2.2 2\. Goal setting](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#2._Goal_setting) - [6\.2.3 3\. Postural Control](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#3._Postural_Control) - [7 Outcome measures](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Outcome_measures) - [7\.1 Pain](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Pain) - [7\.1.1 Visual Analogue Scale (VAS)](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Visual_Analogue_Scale_\(VAS\)) - [7\.2 Disability](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Disability) - [7\.2.1 Roland-Morris Disability Questionnaire (RMDQ)](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Roland-Morris_Disability_Questionnaire_\(RMDQ\)) - [7\.2.2 Oswestry Disability Index (ODI)](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Oswestry_Disability_Index_\(ODI\)) - [7\.3 Physical activity](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Physical_activity) - [7\.3.1 International Physical Activity Questionnaire (IPAQ)](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#International_Physical_Activity_Questionnaire_\(IPAQ\)) - [8 Suggestions for Future Clinical Research](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#Suggestions_for_Future_Clinical_Research) - [9 References](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#References) Related online courses on \+Physiopedia Plus [![](https://swiftype-ss.imgix.net/https%3A%2F%2Fmembers.physio-pedia.com%2Fwp-content%2Fuploads%2F2022%2F03%2FManaging-Low-Back-Pain-with-Integrative-Lifestyle-Medicine-Programme-300x169.jpeg?ixlib=rb-1.1.0&h=320&fit=clip&dpr=2.0&s=42d4ba6f776e567058e73fd1be29b473) Online Course: Managing Low Back Pain with Integrative Lifestyle Medicine Programme Low Back Pain with Integrative Lifestyle Medicine Programme Use a holistic approach to empower your clients and provide holistic care treatment for chronic LBP Start course 11-13 hours - - - - Powered by Physiopedia Course instructor Z Altug Ziya "Z" is a physical therapist specialising •](https://members.physio-pedia.com/learn/managing-low-back-pain-with-integrative-lifestyle-medicine-programme-promopage/?utm_source=physiopedia&utm_medium=related_courses_mobile&utm_campaign=ongoing_internal) [![](https://swiftype-ss.imgix.net/https%3A%2F%2Fmembers.physio-pedia.com%2Fwp-content%2Fuploads%2F2022%2F03%2FLifestyle-Medicine-and-Office-Ergonomic-Strategies-for-Managing-Low-Back-Pain-300x169.jpg?ixlib=rb-1.1.0&h=320&fit=clip&dpr=2.0&s=04f5116ad2ac7ee3f46ebcbec48bede5) Online Course: Lifestyle Medicine and Office Ergonomic Strategies for Managing Low Back Pain Lifestyle Medicine and Office Ergonomic Strategies for Managing Low Back Pain A holistic approach to managing LBP for the office worker Start course 1-1.5 hours - - - - Powered by Physiopedia Course instructor Z Altug Ziya "Z" is a physical therapist specialising in lifestyle medicine Summarising •](https://members.physio-pedia.com/learn/lifestyle-medicine-and-office-ergonomic-strategies-for-managing-low-back-pain-promopage/?utm_source=physiopedia&utm_medium=related_courses_mobile&utm_campaign=ongoing_internal) [![](https://swiftype-ss.imgix.net/https%3A%2F%2Fmembers.physio-pedia.com%2Fwp-content%2Fuploads%2F2022%2F03%2FIntroduction-to-Managing-Chronic-Low-Back-Pain-with-Integrative-Lifestyle-Medicine-300x169.jpeg?ixlib=rb-1.1.0&h=320&fit=clip&dpr=2.0&s=2d7777166658f0d7e9de90983dbac631) Online Course: Introduction to Managing Chronic Low Back Pain with Integrative Lifestyle Medicine Introduction to Managing Chronic Low Back Pain with Integrative Lifestyle Medicine Learn the basics of holistic treatment for chronic LBP Start course 1-1.5 hours - - - - Powered by Physiopedia Course instructor Z Altug Ziya "Z" is a physical therapist specialising in lifestyle medicine Summarising •](https://members.physio-pedia.com/learn/introduction-to-managing-chronic-low-back-pain-with-integrative-lifestyle-medicine-promopage/?utm_source=physiopedia&utm_medium=related_courses_mobile&utm_campaign=ongoing_internal) [![](https://swiftype-ss.imgix.net/https%3A%2F%2Fmembers.physio-pedia.com%2Fwp-content%2Fuploads%2F2022%2F03%2FLifestyle-Medicine-Exercise-and-Nutrition-for-Managing-Chronic-Low-Back-Pain-300x169.jpeg?ixlib=rb-1.1.0&h=320&fit=clip&dpr=2.0&s=b3b5d69069dd6a8e9cb80b3da43e418c) Online Course: Lifestyle Medicine, Exercise and Nutrition for Managing Chronic Low Back Pain Lifestyle Medicine, Exercise and Nutrition for Managing Chronic Low Back Pain Enrich your knowledge of integrative exercises and nutrition and confidently prescribe holistic treatments for chronic LBP Start course 1-1.5 hours - - - - Powered by Physiopedia Course instructor Z Altug Ziya "Z" is a physical •](https://members.physio-pedia.com/learn/lifestyle-medicine-exercise-and-nutrition-for-managing-chronic-low-back-pain-promopage/?utm_source=physiopedia&utm_medium=related_courses_mobile&utm_campaign=ongoing_internal) [![](https://swiftype-ss.imgix.net/https%3A%2F%2Fmembers.physio-pedia.com%2Fwp-content%2Fuploads%2F2022%2F01%2Fsleep-wellness-300x169.jpg?ixlib=rb-1.1.0&h=320&fit=clip&dpr=2.0&s=978d68d67992db07f935438abf596a87) Online Course: Lifestyle Medicine, Sleep Hygiene and Psychological Well-Being for Managing Chronic Low Back Pain Lifestyle Medicine, Sleep Hygiene and Psychological Well-Being for Managing Chronic Low Back Pain Break the sleep-pain\-stress cycle for your patients with chronic low back pain using integrative exercises and whole-person treatments Start course 1-1.5 hours - - - - Powered by Physiopedia Course instructor Z •](https://members.physio-pedia.com/learn/lifestyle-medicine-sleep-hygiene-and-psychological-well-being-for-managing-chronic-low-back-pain-promopage/?utm_source=physiopedia&utm_medium=related_courses_mobile&utm_campaign=ongoing_internal) [![](https://members.physio-pedia.com/wp-content/uploads/2022/03/Managing-Low-Back-Pain-with-Integrative-Lifestyle-Medicine-Programme.jpeg)ONLINE COURSE Managing Low Back Pain with Integrative Lifestyle Medicine Programme Professional development from Physiopedia Plus](https://members.physio-pedia.com/learn/managing-low-back-pain-with-integrative-lifestyle-medicine-programme-promopage/?utm_source=physiopedia&utm_medium=related_courses_normal_vertical&utm_campaign=ongoing_internal) [![](https://members.physio-pedia.com/wp-content/uploads/2022/03/Lifestyle-Medicine-and-Office-Ergonomic-Strategies-for-Managing-Low-Back-Pain.jpg)ONLINE COURSE Lifestyle Medicine and Office Ergonomic Strategies for Managing Low Back Pain Get your CEUs / CPD points from Physiopedia](https://members.physio-pedia.com/learn/lifestyle-medicine-and-office-ergonomic-strategies-for-managing-low-back-pain-promopage/?utm_source=physiopedia&utm_medium=related_courses_normal_vertical&utm_campaign=ongoing_internal) [![](https://members.physio-pedia.com/wp-content/uploads/2022/03/Introduction-to-Managing-Chronic-Low-Back-Pain-with-Integrative-Lifestyle-Medicine.jpeg)ONLINE COURSE Introduction to Managing Chronic Low Back Pain with Integrative Lifestyle Medicine AI supported learning powered by Physiopedia](https://members.physio-pedia.com/learn/introduction-to-managing-chronic-low-back-pain-with-integrative-lifestyle-medicine-promopage/?utm_source=physiopedia&utm_medium=related_courses_normal_vertical&utm_campaign=ongoing_internal) [![](https://members.physio-pedia.com/wp-content/uploads/2022/03/Managing-Low-Back-Pain-with-Integrative-Lifestyle-Medicine-Programme.jpeg)ONLINE COURSE Managing Low Back Pain with Integrative Lifestyle Medicine Programme Professional development from Physiopedia Plus](https://members.physio-pedia.com/learn/managing-low-back-pain-with-integrative-lifestyle-medicine-programme-promopage/?utm_source=physiopedia&utm_medium=related_courses_mobile_vertical&utm_campaign=ongoing_internal) ## Introduction\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=1 "Edit section: Introduction") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=1 "Edit section: Introduction")\] [Low back pain](https://www.physio-pedia.com/Low_Back_Pain) (LBP) that is not associated with serious or potentially serious causes has been described in the literature as '[non-specific](https://www.physio-pedia.com/Non_Specific_Low_Back_Pain)', 'mechanical', 'musculoskeletal', or 'simple' LBP.[\[1\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1) [Non-specific](https://www.physio-pedia.com/Non_Specific_Low_Back_Pain) LBP is defined as LBP not attributable to a recognisable specific pathology (eg, infection, tumor, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome).[\[2\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-2) [![](https://www.physio-pedia.com/images/thumb/3/3e/Lower_back_pain.png/200px-Lower_back_pain.png)](https://www.physio-pedia.com/File:Lower_back_pain.png) LBP between the rib cage and gluteal folds LBP can be further split into three categories; acute, sub-acute, and [chronic](https://www.physio-pedia.com/Chronic_Low_Back_Pain).[\[3\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-3) 1. Acute is anything that persists for less than 6 weeks. 2. Sub-acute is anything persisting between 6-12 weeks. 3. [Chronic](https://www.physio-pedia.com/Chronic_Low_Back_Pain) is anything persisting for 12 weeks or more. LBP is commonly described to be between the anatomical regions of the ribs and gluteal folds.[\[4\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:1-4) ## Anatomy\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=2 "Edit section: Anatomy") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=2 "Edit section: Anatomy")\] The [lumbar spine](https://www.physio-pedia.com/Lumbar_Anatomy "Lumbar Anatomy") comprises the lower end of the spinal column between the last [thoracic](https://www.physio-pedia.com/Thoracic_Anatomy "Thoracic Anatomy") vertebra (T12) and the first [sacral vertebra](https://www.physio-pedia.com/Sacrum "Sacrum") (S1). There is a total of five lumbar vertebrae (L1-L5) that are much larger compared to other regions within the vertebral column. These large [facets](https://www.physio-pedia.com/Facet_Joints "Facet Joints") help support the upper body, as they absorb axial forces (against gravity) delivered from the head, neck, and trunk, and provide protection for the spinal cord from the canal that is formed. The lumbar spine allows for diverse types of trunk motion, including flexion, extension, rotation, and side bending, thus providing further reasons as to why the facets are much larger. Each lumbar segment consists of multiple components; vertebral body, transverse process, super articular process, super articular facet, intervertebral disc, vertebral forearm, the pedicle of the vertebral arch, lamina of the vertebral arch, and a spinous process.[\[5\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-5) Due to the complex structure of spinal components, discs, intervertebral joints, muscles, and nerves, LBP can present with the same symptoms from different causes. ## Epidemiology\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=3 "Edit section: Epidemiology") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=3 "Edit section: Epidemiology")\] LBP causes more disability than any other condition, affecting 1 in 10 people and becoming more common with increasing age, [\[1\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1)with rates of 1%–6% in children aged 7–10 years, 18% in adolescents, and a peak prevalence ranging from 28% to 42% in people between 40 years and 69 years.[\[6\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:3-6) The prevalence of LBP is thought to be increasing due to an increasing and aging population [\[7\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-7) with estimates of life time prevalence being as high as 84% in the adult population. [\[8\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-8) [![](https://www.physio-pedia.com/images/thumb/6/6f/Picture_.png/300px-Picture_.png)](https://www.physio-pedia.com/File:Picture_.png) [The age-specific point prevalence of low back pain in 2017, by gender.](https://atm.amegroups.com/article/view/38037/html)[\[9\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-9) One study that was carried out in 195 countries assessing the incidence, prevalence, and years lived with disability for 354 medical conditions found LBP to be the leading cause of worldwide productivity loss as measured in years, and the top cause of years lived with disability in 126 countries.[\[6\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:3-6) In the United Kingdom (UK), it is estimated that LBP is responsible for 37% of all [chronic pain](https://www.physio-pedia.com/Chronic_Pain_and_the_Brain "Chronic Pain and the Brain") in men and 44% in women and the total cost of LBP to the UK economy is reckoned to be over £12 billion per year. [\[1\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1) Risk factors for LBP are age, sex, height, weight, sedentary lifestyle, depression, anxiety, insomnia, and smoking.[\[10\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-10) Although muscle strain and imbalance, ligament sprain, and soft tissue damage account for almost all LBP, as it is [non-specific](https://www.physio-pedia.com/Non_Specific_Low_Back_Pain), it often has no identifiable underlying condition or origin. [\[11\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-11) Office workers are usually required to sit for long hours working on a computer while spending most of their time in a sitting position. Approximately 34%- 51% of office workers experienced LBP in the preceding 12 months. Occupational groups exposed to 'poor postures' while sitting for longer than half a day have a considerably increased risk of experiencing LBP. Subjects with LBP are likely to be in sustained postures and have large and infrequent spinal movements. Prolonged postural loading of the spine while sitting can reduce joint lubrication, fluid content of intervertebral discs, and increased stiffness. Additionally to this, prolonged muscle activation in static sitting may lead to localised muscle tension, muscle strains, muscle fatigue, and other soft-tissue damage, causing impairment of motor coordination and control as well as increased mechanical stress on ligaments and intervertebral discs.[\[12\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-12) Prevalence of [walking in the United Kingdom](https://www.gov.uk/government/statistics/walking-and-cycling-statistics-england-2020/walking-and-cycling-statistics-england-2020): - People made an average of 236 walking trips and walked an average of 220 miles. - People on average have walked less than in 2019, following a fall in short walks. - People walked 7% farther in 2020 compared to 2019. - 67% of adults in England reported walking at least once a week. - 92% of local authorities had at least 60% of their adult population walking at least once a week. The NHS provides a guide on ['walking for health'](https://www.nhs.uk/live-well/exercise/running-and-aerobic-exercises/walking-for-health/), to help motivate the population and help them meet the recommended minimum moderate activity guidelines of 150 minutes. ## Pedometer Driven Walking\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=4 "Edit section: Pedometer Driven Walking") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=4 "Edit section: Pedometer Driven Walking")\] [![](https://www.physio-pedia.com/images/f/f9/Pedometer._jp.jpg)](https://www.physio-pedia.com/File:Pedometer._jp.jpg) Example of a pedometer [Pedometers](https://www.prevention.com/fitness/a20450112/walking-tips-how-to-use-a-pedometer/) are devices that work by counting the steps someone takes to estimate the distance they have traveled. [\[13\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-13) Pedometers are usually worn at the hip (on the waistband of clothing) and in alignment with the patella although this may not be the case for all pedometers. There are also other ways of tracking steps - many people now have fitness trackers which are attached to the wrist and will also have the ability to count steps. Instructions will be included with pedometer devices, and as there are many [different types](https://www.prevention.com/fitness/a20450112/walking-tips-how-to-use-a-pedometer/) it is important to check these before usage to ensure that the pedometer is being used as accurately as possible. Some pedometers may also be more complex and do a little bit more than just counting steps such as showing calories burned, activity times, and memory logs. Whilst not a pedometer in the traditional sense, the [NHS](https://www.nhs.uk/better-health/get-active/) (National Health Service) also has an application which is free to download called 'Active 10' - this is designed to track walking and will indicate the total amount walked and how much of that was brisk walking. Within the app, there are also options to set goals, achieve milestones, and view progress over the weeks and months. So a pedometer is not the only option to keep a track of walking and daily activity - there are many more apps out there that will do the same thing\! Using an app as a pedometer or walking tracker does rely on the individual having a mobile phone and keeping it in their pocket to ensure it tracks all activity whereas a standard pedometer can be used by a wider number of people and may not be as complex. ### Do Pedometers Increase Physical Activity?\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=5 "Edit section: Do Pedometers Increase Physical Activity?") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=5 "Edit section: Do Pedometers Increase Physical Activity?")\] [The NICE (National Institute for Health and Care Excellence) guidelines](https://www.nice.org.uk/news/article/nice-publishes-updated-advice-on-treating-low-back-pain) on LBP and sciatica in over 16s - published in 2016 and last updated in 2020 - advises self-management and exercise as treatments. [\[1\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1)A pedometer would be an easy way of giving someone a tool to help self-manage their activity levels, as long as this was an appropriate choice of exercise for the individual - those with LBP should be encouraged to continue with their regular activities as well. [\[1\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1) A three-arm cluster, randomised control trial (RCT) conducted in 2016 with an eventual number of participants at 956 recruited from primary care settings, found that a pedometer-based walking intervention (regardless of whether there was nurse support) increased the step count and physical activity of generally inactive 45-75 year old at a 12 month follow up. [\[14\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-14)A meta-analysis in 2009 of pedometer-based interventions for activity conducted in 2013 included 32 studies and found using pedometers to have a positive effect on physical activity and this was regardless of age or intervention length.[\[15\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:13-15) The studies had varying interventions from keeping a daily log of steps, completing 10,000 steps, individualized goals, or a combination of strategies.[\[15\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:13-15) ### Do Pedometers Affect LBP?\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=6 "Edit section: Do Pedometers Affect LBP?") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=6 "Edit section: Do Pedometers Affect LBP?")\] #### Acute Low Back Pain (ALBP)\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=7 "Edit section: Acute Low Back Pain (ALBP)") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=7 "Edit section: Acute Low Back Pain (ALBP)")\] There is arguably less research in relation to ALBP and the effects of using a pedometer. However, a study in 2015, focusing on those with ALBP of 48 hours or less looked at whether 'stay active' advice or 'adjusting activities to pain' had different effects. [\[16\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:14-16) Participants were aged between 18 and 65 and all were provided with a pedometer to track daily steps with the instruction of wearing it at all times during waking hours, they found the pedometer an easily used intervention which increased physical activity, particularly in those with the advice to 'stay active'.[\[16\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:14-16) This study shows that pedometers could have a useful place in treatment alongside other advice and management techniques for those with ALBP despite the study being over a short period of time, and the study size is relatively small. #### Chronic Low Back Pain (CLBP)\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=8 "Edit section: Chronic Low Back Pain (CLBP)") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=8 "Edit section: Chronic Low Back Pain (CLBP)")\] As previously mentioned, [CLBP](https://www.physio-pedia.com/Chronic_Low_Back_Pain "Chronic Low Back Pain") accounts for a significant amount of chronic pain in individuals of the UK, so interventions that aid in the treatment and management would be beneficial. A recent RCT published in 2021, looked at the effects of a pedometer-driven individualized walking plan compared to standardised care in increasing completion and adherence of physical activity in CLBP management.[\[17\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:15-17)Whilst no significant difference was noted in disability or pain, there was an indication that using an individualised, guided pedometer program aided in adherence and participation of physical activity - although relevant measures such as step count were not taken from the standardised care group, so it is unclear if there were any increases in physical activity amongst them.[\[17\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:15-17) A previous RCT from 2013, of an internet-based pedometer intervention, did find that in the short-term of 6 months back pain disability had decreased, but at 12 months there was no difference between the group with access to the internet support and the ones utilising the pedometer and standard management only.[\[18\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-18)Again, this shows, that whilst pedometer-driven walking can have positive effects in physical activity and adherence, there may need to be further research to explore how positive outcomes can be gained in the long term. It seems that pedometers can be a relatively cheap and accessibly form of intervention and management in individuals with LBP, and this can have greater positive impacts when included with support in one form or another.[\[16\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:14-16) ## Benefits of Walking on Low Back Pain\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=9 "Edit section: Benefits of Walking on Low Back Pain") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=9 "Edit section: Benefits of Walking on Low Back Pain")\] [![Walking dog.jpg](https://www.physio-pedia.com/images/thumb/b/b8/Walking_dog.jpg/300px-Walking_dog.jpg)](https://www.physio-pedia.com/File:Walking_dog.jpg) The lower back muscles play an important role in maintaining its stability and movement; two key aspects that are needed when walking. [\[19\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:6-19) These [muscles](https://www.physio-pedia.com/Muscle "Muscle") can become deconditioned in those with sedentary lifestyles, leading to weakness over time. This prolonged weakness can increase muscular fatigue, and injury, exaggerating the pain already being experienced. [\[19\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:6-19) Reduced physical activity can also cause these muscles and the joints of the [lumbar spine](https://www.physio-pedia.com/Lumbar_Anatomy "Lumbar Anatomy") to become stiff, which can increase the pressure on the lower back. [\[20\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:7-20) [Walking has many positive impacts on the lower back](https://www.verywellfit.com/walking-away-low-back-pain-3435479#toc-does-walking-really-prevent-low-back-pain), which can prevent or reduce these changes occurring in the following ways: 1. Increased blood flow: - Small blood vessels and capillaries in the lower back muscles can become constricted following decreased physical activity, [reducing the blood flow](https://www.spine-health.com/blog/2-reasons-why-walking-good-your-lower-back#vh_footnotes) to these muscles. - Walking allows for more movement in these muscles, allowing these capillaries and blood vessels to open up again. - This, in turn, increases the blood supply and nutrients to these muscles, improving muscular health and strength and aiding with the healing process. [\[20\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:7-20) 2. Stretch and contraction of muscles: - The movement in the lower back during walking increases the stretch and contraction of the lower back muscles and those in the legs, buttocks, and core, allowing for more flexibility and mobility in this area. - This flexibility [increases the overall range of motion](https://www.spine-health.com/blog/2-reasons-why-walking-good-your-lower-back#vh_footnotes) in the lower back, also improving the health and strength of the lower back muscles. [\[21\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-21) ## Treatment and Management\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=10 "Edit section: Treatment and Management") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=10 "Edit section: Treatment and Management")\] ### Effect Of Walking On LBP\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=11 "Edit section: Effect Of Walking On LBP") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=11 "Edit section: Effect Of Walking On LBP")\] Current evidence supports the use of walking as a treatment option for LBP. A cross-sectional study from 2017 evaluating the relationship between walking and LBP, consisting of 5,982 adults, found that walking was associated with a reduced risk of LBP. [\[22\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:9-22) The authors also found that the presence of LBP was proportionate to walking frequency, with those who walked more often having reduced LBP. These results are supported by those of a systematic review from 2019 evaluating the effects of walking on those with chronic LBP. [\[23\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:10-23) Walking was found to be as effective as other non-pharmacological interventions on pain and disability in short-term (\<3 months) and intermediate (3-12 months) follow-ups. These findings allowed for walking to be recommended for managing and treating LBP. [\[23\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:10-23) The effects of walking have been compared to the effects of exercise for LBP. A systematic review from 2019 comparing the two concluded that walking was as effective as exercise for improving pain, disability, quality of life, and fear-avoidance in those with chronic LBP. [\[24\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:11-24) Much like the studies by Kim et al. [\[22\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:9-22) and Sitthipornvorakul et al. [\[23\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:10-23), Vanti et al. [\[24\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:11-24) recommend the use of walking as a treatment and management option for LBP. Interestingly, a systematic review from 2022, found that people with LBP have altered gait patterns compared with healthy individuals. [\[25\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:12-25) Those with LBP were found to walk slower, have reduced stride lengths, greater lumbar paraspinal activation, and reduced thorax/pelvic coordination. [\[25\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:12-25) However, the authors were unable to report if these changes were adaptive or maladaptive. Overall, these results indicate that gait re-education may be needed for those with LBP to gain the most benefits from walking. A systematic review in 2015 included seven randomised controlled trials involving 869 participants adults with chronic LBP. It compared walking to other non-pharmacological management methods such as usual care, specific strength exercises, medical exercise therapy, or supervised exercise classes. It suggested that walking is the same effective as other management methods while having a lower cost. [\[26\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:18-26). It could be explained by its high accessibility, but does not require training, supervision, or specialised equipment. [\[26\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:18-26) Other research supported that walking is as effective as conventional physiotherapy treatment such as lumbar stabilisation and muscle strengthening exercise. [\[27\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:19-27)[\[28\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:20-28) A randomised control trial included 48 participants comparing the effect of lumbar stabilisation exercise and walking exercise on LBP. It suggested both interventions significantly reduced LBP, and both interventions show similar results.[\[28\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:20-28) Another randomised control trial compare strengthening exercise to a combined programme of strengthening exercise and walking exercise on chronic LBP. It suggested that both interventions were beneficial but combined exercise programme was more effective for reducing pain levels than the strength exercise. [\[27\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:19-27)Another randomised control trial also supported 44 participants comparing conventional physiotherapy to a combination of conventional physiotherapy with walking exercise. It suggested that a combination of conventional physiotherapy with walking exercise is more effective to reduces pain and kinesiophobia, and improved function in patients with subacute and chronic non-specific LBP. [\[29\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:21-29) ### How to Use Walking as a Treatment for LBP\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=12 "Edit section: How to Use Walking as a Treatment for LBP") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=12 "Edit section: How to Use Walking as a Treatment for LBP")\] #### 1\. Combine with conventional physiotherapy treatment\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=13 "Edit section: 1. Combine with conventional physiotherapy treatment") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=13 "Edit section: 1. Combine with conventional physiotherapy treatment")\] Walking is a low-cost intervention, and a combination of physiotherapy with walking is more effective than conventional physiotherapy alone. [\[26\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:18-26)[\[27\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:19-27)[\[29\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:21-29) Walking exercise could be educated by physiotherapists alongside their exercise prescription. Recommendations support the use of exercise for at least 15 to 30 minutes most days for those with LBP. [\[30\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-30) This can mean gradually building up walking distance and capacity to reduce the risk of injury and allow for the body to adapt to the changes. #### 2\. Goal setting\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=14 "Edit section: 2. Goal setting") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=14 "Edit section: 2. Goal setting")\] The use of a pedometer means that the patient is able to manage and keep track of their steps whilst walking. The patient might be advised to keep an "activity diary" which keeps track of a daily step count and the patient's step goal. This is achieved by calculating the patient's average step count in the first week of activity, and using this as a baseline when deciding a step goal for the second week. [\[31\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:22-31) The use of an activity diary can also help establish the patients' baseline in the first week, which is important in informing their individual goals for rehabilitation. [\[31\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:22-31) For example, use pedometer/tracking apps (like Active 10) to monitor and then set weekly targets (increase by a certain amount each week/two weeks for example). #### 3\. Postural Control\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=15 "Edit section: 3. Postural Control") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=15 "Edit section: 3. Postural Control")\] Having the [correct walking posture](https://www.verywellfit.com/how-to-walk-walking-posture-3432476) is important to allow for more comfortable walking, helping to reduce pain and discomfort. An optimal posture can be achieved using multiple strategies: 1. Stand up straight: - This can be achieved by making yourself as tall as possible, without leaning forwards or backward. - Ensuring your chin is kept up and your eyes facing forwards allows for reduced strain on your neck and back. - These together will allow for a better posture and improved balance. [\[32\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-32) 2. Keep shoulders back and relaxed: - Relaxing your shoulders helps relieve tension and allows for a more neutral spine when walking. 3. Engage core muscles and keep a neutral pelvis: - engaging your core and keeping a neutral pelvis prevents arching of the spine and tilting of the pelvis, allowing for a more neutral spine and better posture. [\[33\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-33) ## Outcome measures\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=16 "Edit section: Outcome measures") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=16 "Edit section: Outcome measures")\] There are a variety of outcome measures that might be used when advising walking as a management strategy for patients with LBP. These might look at: - Pain - Disability - Physical activity ### Pain\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=17 "Edit section: Pain") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=17 "Edit section: Pain")\] #### Visual Analogue Scale (VAS)\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=18 "Edit section: Visual Analogue Scale (VAS)") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=18 "Edit section: Visual Analogue Scale (VAS)")\] The VAS ([Visual Analogue Scale](https://www.physio-pedia.com/Visual_Analogue_Scale "Visual Analogue Scale")) is one of the most common outcome measures for LBP. [\[34\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-34) It is an example of a subjective PROM (Patient Reported Outcome Measure), where the patient records their pain on a 100mm line- from "no pain" at the beginning to the "worst pain imaginable". Some types of VAS also use faces to represent pain from "mild", "moderate" to "severe", as shown below. [![](https://www.physio-pedia.com/images/thumb/0/02/Visual_Analogue_Scale.jpg/300px-Visual_Analogue_Scale.jpg)](https://www.physio-pedia.com/File:Visual_Analogue_Scale.jpg) Examples of a VAS [\[35\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-35) Previous studies have found that the VAS is a "reliable and valid" outcome measure for use in a LBP population. [\[36\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-36) It has also shown reliability in predicting disability due to LBP. [\[37\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-37) ![Logo](https://www.physio-pedia.com/skins/PhysiopediaSkin/resources/images/plus-new-logo-white.png) ## Introducing PAI - Your AI Clinical Partner in Physiotherapy Enhance your clinical reasoning, minimise paperwork and maximise patient interaction [Yes please\!](https://members.physio-pedia.com/physiopedia-ai-assistant/?utm_source=physiopedia&utm_medium=content_advert&utm_campaign=standard_pai_ad_left_img) ### Disability\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=19 "Edit section: Disability") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=19 "Edit section: Disability")\] #### Roland-Morris Disability Questionnaire (RMDQ)\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=20 "Edit section: Roland-Morris Disability Questionnaire (RMDQ)") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=20 "Edit section: Roland-Morris Disability Questionnaire (RMDQ)")\] The [Roland-Morris Disability questionnaire (RMDQ)](https://www.physio-pedia.com/Roland%E2%80%90Morris_Disability_Questionnaire "Roland‐Morris Disability Questionnaire") is a commonly used PROM, designed to assess a patient's disability in relation to their LBP. It is a 24-item questionnaire that looks at physical functions that the patient feels have been affected, and a higher score represents a higher level of disability due to LBP. [\[38\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-38) [![](https://www.physio-pedia.com/images/thumb/0/0d/RMDQ_picture.webp/390px-RMDQ_picture.webp.png)](https://www.physio-pedia.com/File:RMDQ_picture.webp) An example of the RMDQ [\[39\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-39) A study from 2020 found that the RMDQ had good test-retest reliability and internal consistency reliability in capturing the "everyday functional impact of low back pain". [\[40\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-40) #### Oswestry Disability Index (ODI)\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=21 "Edit section: Oswestry Disability Index (ODI)") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=21 "Edit section: Oswestry Disability Index (ODI)")\] The [Oswestry Disability Index (ODI)](https://www.physio-pedia.com/Oswestry_Disability_Index "Oswestry Disability Index") is also commonly used to assess functional disability in patients with LBP. [\[41\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-41) It consists of 10 items which are detailed below, as well as the interpretation of the scores. [![](https://www.physio-pedia.com/images/thumb/4/41/ODI_QUESTIONS.jpg/390px-ODI_QUESTIONS.jpg)](https://www.physio-pedia.com/File:ODI_QUESTIONS.jpg) Oswestry Disability Index (ODI) [\[42\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-42) [![](https://www.physio-pedia.com/images/thumb/8/85/ODI_interpretation.png/300px-ODI_interpretation.png)](https://www.physio-pedia.com/File:ODI_interpretation.png) Interpretation of ODI scores [\[43\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-43) The ODI has been found to be a "valid and reliable scale suitable for measurement of disability for low back pain", and in particular showing high test-retest reliability. [\[44\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-44) A study looked at comparing the ODI and the RMDQ to each other. The study found that the ODI appeared to be better at detecting changes in patients with more severe lower back pain, whereas the RMDQ seemed to have an advantage when measuring patients who had more mild disability.[\[45\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-45) ### Physical activity\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=22 "Edit section: Physical activity") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=22 "Edit section: Physical activity")\] #### International Physical Activity Questionnaire (IPAQ)\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=23 "Edit section: International Physical Activity Questionnaire (IPAQ)") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=23 "Edit section: International Physical Activity Questionnaire (IPAQ)")\] The International Physical Activity Questionnaire (IPAQ) is formed of two different versions including the IPAQ short-form and the IPAQ long version. Both versions require the patient to recall their physical activity levels in the past 7 days. Based on these scores, they are placed in one of three categories: low activity levels, moderate activity levels, and high activity levels. [\[46\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-46) The [IPAQ short-form](https://evaluationframework.sportengland.org/media/1084/2015-ipaq-sf.pdf) consists of 4 categories where the patient reports how much they participated in the following activities in the past 7 days: - Moderate activity - Vigorous activity - Time spent walking - Time spent sitting The IPAQ short-form may be more beneficial for use in a clinical setting due to the shorter/more accessible nature of the questionnaire for patients. [\[47\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:2-47) The [IPAQ long version](https://www.physio-pedia.com/images/6/6e/International_Physical_Activity_Questionaire) assesses physical activity across 5 domains: 1. Job-related physical activity 2. Transportation physical activity 3. Housework, house maintenance, and caring for family 4. Recreation, sport, and leisure time 5. Time spent walking The IPAQ long version is typically used in research studies or may be used if a more detailed picture of a patient's physical activity levels is preferred. [\[47\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:2-47) Overall, the [IPAQ](https://www.physio-pedia.com/images/6/6e/International_Physical_Activity_Questionaire) has been subject to extensive reliability and validity testing across 12 different countries (14 sites) from 2000 as an outcome measure for physical activity. ## Suggestions for Future Clinical Research\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=24 "Edit section: Suggestions for Future Clinical Research") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=24 "Edit section: Suggestions for Future Clinical Research")\] - Based on the current literature, walking has been shown to be an effective management strategy for patients with LBP. However, more high-quality RCT’s need to be carried out using a variety of outcome measures, including physical activity, to further investigate walking as an effective management strategy for LBP. - In order to strengthen the current evidence around this topic, further research could be carried out on how to ensure the long term effects of pedometer-based intervention. It would also be valuable to investigate whether added interventions might be necessary in aiding supportive positive outcomes long-term. - The current NICE guidelines for LBP and sciatica were published in 2016 and updated in 2020 for pharmacological interventions. However, the advice for “non-pharmacological interventions” last had an evidence review in 2016\. Therefore, it may be beneficial for a reassessment based on new evidence, in which guidelines around walking could be evaluated. Related articles [Inactivity and Low Back Pain - Physiopedia Introduction According to NICE Guideline,p ublished in30 November 2016 and updated in December 2020 , the lower back can be defined as the area between the 12th ribs and the buttock creases.\[1\] "Non-specific" low back pain is defined as low back pain not attributable to a recognisable, known specific pathology (e.g. infection, tumour, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome).\[2\] The time frame of low back pain classification:\[3\] Acute low back pain – symptoms less than 6 weeks Sub-acute low back pain – symptoms last between 7-12 weeks Chronic low back pain – symptoms last more than 12 weeks \[4\] You can find guidelines regarding low back pain here. Physical Activity and Inactivity\[edit \\| edit source\] “Physical activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure.”\[5\] Physical activity includes activities of daily living, such as walking, housework, gardening, and work-related activities.\[6\] When an individual does not meet the recommended level of physical activity, he or she will be classified as physically inactive. The 2013 NICE Guideline recommendations (UK Chief Medical Officers’ physical activity recommendations) for physical activity state the following:\[6\] All adults aged 19 years and over should aim to be active daily Over one week, daily activity should add up to at least 150 minutes (2.5 hours) of moderate intensity physical activity in bouts of 10 minutes or more Alternatively, comparable benefits can be achieved through 75 minutes of vigorous intensity activity spread across the week or combinations of moderate and vigorous intensity activities All adults should also undertake physical activity to improve muscle strength on at least 2 days per week All adults should minimise the amount of time spent being sedentary (sitting) for extended periods Older adults (65 years and over) who are at risk of falls should incorporate physical activity to improve balance and coordination at least 2 days per week Individual physical and mental capabilities should be considered when interpreting the guidelines, but the key message is that some activity is better than no activity The World Health Organisation (WHO) has classified physical inactivity into two levels. Level 1 exposure (inactive): an individual does very little or no physical activity at home, work, for transport or in his/her private time Level 2 exposure (insufficiently active): an individual does physical activity less than 150 minutes of moderate-intensity or 60 minutes of vigorous-intensity physical activity in all activities of daily living.\[7\] The current levels of physical inactivity are partly due to insufficient participation in physical activity during leisure time and an increase in sedentary behaviour during occupational and domestic activities.\[8\] Sedentary Behaviour\[edit \\| edit source\] National guidelines classify people as sedentary when an individual does less than 30 minutes of moderate activity on all or most days of the week.\[9\] Sedentary behaviour describes activities that do not increase energy expenditure significantly above the resting level. It includes activities such as sleeping, lying, watching television ,and other types of screen-based entertainment. However, light physical activity is often mistaken as sedentary behaviour, such as slow walking, sitting, writing, and cooking, but these do require energy expenditure above the resting level.\[10\] Low Back Pain- Statistics\[edit \\| edit source\] One-third of the United Kingdom adult population is affected by low back pain each year 20% (1 in 15 of the population) of people will consult a GP about their low back pain\[1\] In Europe, the lifetime prevalence of low back pain can be as high as 84% After the first experience of low back pain, 44-78% of people suffer for relapse of pain again 26-37% of people will have relapses of work absence after an initial episode of low back pain Evidence has shown that the prevalence of chronic non-specific low back pain is around 23%, and 11-12% of the population is disabled by this condition\[11\] 85% of cases are classified as non-specific low back pain as a diagnosis cannot be made by radiological methods\[12\] Regarding IASP (International Association for Study of Pain): "Low back pain is a common global problem. The point prevalence of LBP in 2017 was estimated to be about 7.5% of the global population, or around 577.0 million people \[2\]. LBP has been the leading cause of years lived with disability (YLDs) since 1990 \[2\] and remains a significant global public health concern. 85-95% of people presenting to primary care providers do not have a specific identifiable pathoanatomical origin for their pain \[3\]. The proportion of people presenting to primary care with a specific identifiable cause of LBP is estimated to be 0-7-4.5% with osteoporotic vertebral fractures, 5% with inflammatory spondyloarthropathies4, 0.0-0.7% with malignancy, and 0.01% with infections. The global burden of disability associated with LBP has been increasing since 1990. Disability associated with LBP increased in all age groups between 1990 and 2019 and was greatest in the 50-54 age group in 2019. Approximately 70% of years lost through disability were in working-aged people (20-65 years) There have been increases in both the number of people living with LBP and the prevalence of LBP in all age groups from 1990 to 2017. Although the prevalence of LBP increases with increasing age until 80-89 years, the greatest number of people with LBP globally are currently in the 50-54 year age group. The overall increase in the burden of LBP is likely to be driven by ageing and an increasing population, however, there may be other contributing factors ." Physical Inactivity\[edit \\| edit source\] Around the world, one in five adults is considered physically inactive In developed countries, physical inactivity was found to be more prevalent in women and the elderly Female physical inactivity was higher (21.4%) than male (18.9%)\[13\] Approximately 60% of male adults, 72% of female adults, 68% of boys, and 76% of girls aged 2-15 do not meet the UK Chief Medical Officers’ physical activity recommendations\[14\] Physical inactivity has been reported as the fourth leading risk factor for global mortality (6% of deaths worldwide)\[15\] Around 3.2 million deaths each year are related to insufficient physical activity\[16\] Health Complications\[edit \\| edit source\] Physical inactivity and sedentary behaviour can contribute to the following:\[16\] Hypertension Cardiovascular heart disease Stroke Diabetes Breast and colon cancer Depression Anxiety Risk of falls Obesity Osteoporosis Lipid disorders Low back pain Physical Activity- outcome measures\[edit \\| edit source\] The outcome indicator should be chosen according to how well it measures the objectives of the study. Other important factors in choosing an outcome measure are the level of data required, the characteristics of the individual, group or population, time frame of interest, and the available time and resources.\[17\] Physical activity can be classified as a combination of frequency, intensity, and duration. Any type of activity can be different in terms of the three different aforementioned elements. A better understanding of what element or activity that a study is focused on, the easier it is to determine what outcome measure is most appropriate.\[18\] Measurement of physical activity can be challenging. The outcome measures for physical activity are generally of two types: objective measures (e.g. accelerometers, pedometers, heart-rate monitors, armbands ) subjective measures (e.gself-report questionnaires, self- report Activity Diaries/Logs, Direct Observation). Each has a different degree of validity (i.e. the extent to which an instrument genuinely records what it is intended to measure),\[19\] reliability (i.e. how consistently an instrument or tool will measure something on two or more separate occasions),\[20\] feasibility and practicality. However, there is no ‘gold standard’ for assessing physical activity in public health settings.\[21\]\[22\]\[23\] Below are the options for measuring physical activity suggested in the Standard Evaluation Framework for physical activity interventions, published by the National Obesity Observatory. The measure of a specific type of physical activity Measure of the total physical activity Proportion achieving recommended physical activity levels Public Health England published Standard Evaluation Framework for Weight Management Interventions in February 2018. Self-report approaches are the most frequently used method for measuring physical activity in a public setting due to its cost effectiveness compared to other outcome measures. However, their reliance on recalling activity can be problematic, especially for children and young peopSelf-reportport of physical activity is subject to a number of types of bias, such as recall bias, lack of compliancedesirability desirability’ bias.\[24\] Below is a short list of selected questionnaires for physical activity and diet:\[25\]\[26\] Children and Young People Adults The Physical Activity Questionnaire for Older Children/Adolescents (PAQC/PAQ-A) Youth Risk Behaviour Surveillance Survey (YRBSS) The Teen Health Survey Stanford 7-day recall (7-DR) International Physical Activity Questionnaire Long version (IPAQ-Long) New Zealand Physical Activity Questionnaire (Short Form) (NZPAQ-Short) 7-day Physical Activity Diary A systematic review by Falck et al. 2015 evaluated the measurement tools used in interventions to increase physical activity among older adults, including both objective and subjective measures. 44 studies were included, with 32 of them using self-report measures, 9 using objective measures, and 3 using both. Among all the measures, only 57% of them had population-specific reliability and 66% had population-specific validity. A majority of the studies used self-reported measures, even though many had little evidence of validity and reliability. The researchers of the systematic review suggested that future researchers should use valid and reliable measures of physical activity with well-established evidence of psychometric properties, for instance, hip accelerometers and the Community Health Activities Model Program for Seniors Physical Activity Questionnaire for older adults. With the advance in modern technology, access to technology for measuring physical activity, such as accelerometers and pedometers, is easier than ever, so future researchers sh ld take the opportunity to improve the quality of their studies by using better measurement tools. \[27\] On the other hand, it is important to note that most of the questionnaires were not developed for use in individual or group iterventions, but for population surveillance. In some cases, the tools may not have been sensitive enough to measure the outcome. Furthermore, none of the tools can adequately deta ect change in physical activity over time, but capture more of a snapshot of a particular period of time.\[28\] For Low Back Pain\[edit \\| edit source\] Visual Analogue Scale (VAS) Numerical Pain Rating Scale (NPRS) Roland–Morris Disability Questionnaire (RMDQ) Oswestry disability index (ODI) Pain Self-Efficacy Questionnaire (PSEQ) Patient Specific Functional Scale (PSFS)\[29\] Other Outcome Measures\[edit \\| edit source\] Body Mass Index (BMI), physiological measures, and quality of life are frequently used as secondary outcome measures for physical activity. However, these outcome measures should only be used if they are relevant to the aims ofand the study other researcherinterestsest. Cycle of Physical Inactivity Causing Low Back Pain\[edit \\| edit source\] \[30\] Bone Strength and Disc\[edit \\| edit source\] Bone health is also likely to be affected in an inactive population. According to Wolff’s Law, if the loading on a bone decreases, the bone will become less dense and weaker due to the lack of the stimulus required for continued remodeling and increased resorption from osteoclasts.\[31\] Physical activity can influence bone mass by causing compressive or bending loads on bone. The bone formation will then be the resultant response from the strain/temporary deformation which will trigger primary and secondary responses in bone.\[32\] As such, being physically inactive may put one more at risk of having a low bone mineral density and consequently developing osteoporosis. However, current evidence still lacks high-quality studies to confirm the inverse relationship between back pain and bone health.\[33\]\[34\] A 2015 study demonstrated a 'dose-response relationship' between physical inactivity, including narrow intervertebral disc height. Intervertebral disc narrowing is a feature of degenerative disc disease, suggested by some to be the single most important structural risk factor for low back pain.\[35\] Musculoskeletal\[edit \\| edit source\] Evidence suggests that in response to physical inactivity, skeletal muscles go through a process called adaptive reductive remodeling.\[32\] This results in a loss of muscle mass (atrophy) and changes in muscle composition. Muscle atrophy is characterized by a general reduction in muscle cfibresectional fiber area as well as a reduction in the overall number of mfibresfibers,\[36\] leading to a decrease in muscle strength. Studies have shown that paraspinal muscles atrophy and increase in fat content are associated with low back pain as the result of physical inactivity.\[37\]\[35\] Metabolism\[edit \\| edit source\] Chronic LBP patients who are deconditioned, have their level of activity affected but also other parts of their body . For instance, metabolic factors including carbohydrate and lipid metabolism will become less efficient and effective than healthy non-chronic LBP individuals.\[32\] As a reduced physical activity level will eventually lead to weight gain and a change in body composition, people with LBP are reported to have a higher body fat percentage compared to age- and gender-matched individuals.\[38\] Obesity has been shown to have the strongest association with seeking care for low back pain.\[39\] Factors Affecting Adults Participation in Physical Activity\[edit \\| edit source\] Occupation\[edit \\| edit source\] A person with a job that requires a relatively high demand for physical activity can be sedentary in his leisure time. However, although the physical activity guideline is met he/she may still be considered sedentary but physically active. On the other hand, a person with a sedentary job can be very active in his/her leisure time, and his/her physical activity may meet thuideline and he will not be classified as physically inactive. The type of occupation could affect the amount of physical activity, but it doesn’t necessarily have a direct influence on the physical activity one does during leisure time. The above figure demonstrates time trends for the prevalence of leisure time physical activity (LTPA) and work-related physical activity (WRPA). Values are from the Spanish National Health Interview Survey and are expressed as percentages. Type of occupation\[edit \\| edit source\] International research indicates that blue-collar employees typically exhibit lower rates of leisure-time physical activity. While “lack of time” and “work demands” are commonly reported barriers to activity, a secondary analysis of cross-sectional data from the Australian Health Survey found out among the three categories of occupations (professional, white-collar, and blue-collar), individuals in blue-collar occupations were approximately 50% more likely to be classified as insufficiently active.\[40\] Another systematic review found that white-collar/professionals demonstrated the highest leisure-time physical activity compared to blue-collar workers and concluded that there is convincing evidence that those employed in occupations demanding long work hours and low occupational physical activity are at risk of inactivity.\[41\] From both studies, they showed that there is an association between physical inactivity and type of occupation. Job Position, Job Stres,s and PsychologicMany factors can\[edit \\| edit source\] There are many factors that can affect a person’s physical activity. A cross-sectional study by Martins and Lopes (2013) investigated the association of rank (position of the job in an office setting), job stress, and psychological distress with physical activity in a military setting. The results showed that lower rank (‘high effort and low reward’) was associated with more occupational physical activity, more job stress, and with less physical activity in sports/physical exercise in leisure, and that psychological distress was associated with less physical activity in sports/exercise in leisure.\[42\] Environment\[edit \\| edit source\] The physical environment has a consistent association with physical activity bbehavior One review showed that accessibility, opportunities, and aesthetic attributes had significant associations with physical activity. Weather and safety showed less-strong relationships.\[43\] However, it is hard to isolate one factor from others, other variables affecting physical activity behaviour, and whether the changes are caused by the factor that the researcher is interested in is unknown. A better research model and measurement strategies is needed for future research. Other Factors\[edit \\| edit source\] Personal factors enjoyment of exercise expectation of benefits intention to exercise self-efficacy self-motivation social support from friends/peers/spouse/family lack of time Race/ethnicity Social class etc.\[44\] Evidence For\[edit \\| edit source\] A Dutch cross-sectional study from 2009\[45\] investigated the U-shaped relationship between physical activity and low back pain. The study concluded that both extremes of physical activity, excess activity or insufficient activity, associated with a high risk of LBP. An increased prevalence in LBP was also found in inactive participants with sedentary behavior. In addition, there is a potential gender-related risk for LBP in inactivity because the result is more significant in women compared to men. Another cross-sectional study from 2015\[35\] explored the association between physical inactivity and intervertebral disc height, spinal muscles, fat content and low back pain, and disability. Results concluded that participants with lower activity levels had higher BMI, narrower intervertethe bral disc height, higher fat content of multifidus,and increased risk of high-intensity pain/disability ratio after adjustment for age, gender and BMI. Further details are explained in the following table. Evidence Against\[edit \\| edit source\] A systematic review written in 2011 reviewed 7 studies to look at if patients with chronic low back pain have an altered level and/or pattern of physical activity compared to healthy individuals. The gathered data revealed no significant difference in the overall activity level of adults (18-65 y/o) or adolescents (\<18y/o) with chronic low back pain; however, there is evidence that older adults (\>65 y/o) with chronic low back pain are less active than controls. They concluded that there is no conclusive evidence that patients with chronic low back pain are less active than healthy individuals and there is a lack of studies in this area.\[46\] \[47\] Limitations\[edit \\| edit source\] The current literature looking at physical inactivity causing LBP are mainly cross-sectional studies. However, physical activity is continuous and patterns could change. Therefore, future longitudinal studies will help to better identify this cause and effect relationship.\[48\] Furthermore, pain is complex and difficult to measure due to its subjective nature and it being a multidimensional experience. There is no external reference or gold standard.\[49\] Physical activity is generally measured using self-reported questionnaires, which can lead to overestimation or underestimation. People generally tend to overestimate physical activity and underestimate sedentary behavior\[50\], which reflects the reliability and validity of questionnaires. A more sensitive alternative to questionnaires would be to use objective instruments such as pedometers, accelerometers, or heart rate monitors. Interviews\[edit \\| edit source\] An interview with Grahame Pope, the Head of Physiothe therapy Education at University of Nottingham An interview with Eric Bandoo, a band 6 Physiotherapist at Nottingham Citycare trust](https://www.physio-pedia.com/Inactivity_and_Low_Back_Pain?utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal) [Pain Neuroscience Education (PNE) for Low Back Pain - Physiopedia Introduction Pain Education is an intervention designed to help individuals experiencing chronic pain understand what is happening within their own body's, it aims to reconceptualise pain as a protective output of the brain rather than it being an accurate measure of tissue damage.\[1\] The way it is defined varies dependent on literature but the principles remain the same . \[2\]\[3\]\[4\] Pain education is consistently recommended as an intervention for musculoskeletalconditions as it can be used for both prevention and treatment. \[4\]\[5\] It provides a foundation for better self-informed treatment choices as well as self-monitoring & self-management activities. \[4\] Education Intervention Terms:\[edit \\| edit source\] \[4\] Key messages in Pain Education:\[edit \\| edit source\] Acknowledgement & acceptance of persistent pain Reframing of unhelpful beliefs about LBP Building a support team Pacing (behavioural therapy technique) Learning to prioritise and plan days Setting Goals/Action Plans Being patient with one-self Learning relaxation skills Incorporating stretching & exercise Having back up plans for set backs \[2\]\[3\]\[6\] A systematic review and meta-analysis by Traeger et al. \[2\] provides evidence that all these concepts applied in patient education can reassure patients with chronic pain and such effects are maintained up to 12 months. Pain Neuroscience Education\[edit \\| edit source\] Pain neuroscience education (PNE) consists of educational sessions describing the neurobiology and neurophysiology of chronic pain and processing with particular focus on the role of the Central Nervous System (CNS) on chronic pain and deemphasising anatomical issues.\[7\] It promotes patient understanding of chronic pain and changes maladaptive thoughts and cognitions, for instance, pain catastrophising. \[7\] Through addressing these neurophysiological and neurobiological contributors of pain, PNE has been found to have a short and long-term positive effects on multiple factors, such as pain, disability, catastrophising, overall physical performance and demand on healthcare systems.\[8\] The key messages found within general pain education are also reinforced in pain neuroscience although the mode of delivery can vary. For key concepts of PNE - see here Pain Neuroscience Education delivery strategies:\[edit \\| edit source\] Online module format Single vs Multiple sessions One-to-One vs Group sessions Written vs Online Videos Metaphors Stories Videos \[9\] Low Back Pain\[edit \\| edit source\] Low Back Pain (LBP) has several definitions dependent on the source but majority of literature defines it as "pain, muscle tension or stiffness localised below the costal margin and above the inferior gluteal folds typically, accompanied with or without pain and or neurological symptoms in one or both lower limbs". \[10\] \[11\] For the majority of individuals with LBP, it is not possible to identify a specific nociceptive cause and only a small proportion have well understood pathological causes \[11\] i.e. vertebral fracture, malignancy etc, hence why it is commonly termed as 'non-specific'. It can be categorised in 3 subtypes: acute , sub-acute and chronic. Key concepts, anatomical structures and possible pathological causes - see here LBP is ranked as the highest leading cause of disability globally. \[3\]\[11\] 50-80% of adults experience LBP, it is a common disorder which impacts 2 billion people globally \[12\]\[13\] It is uncommon within the 1st decade of an individuals life but increases steeply during teenage years with around 40% adolescents in high, middle and low income countries reporting of LBP. \[11\] Studies have shown that the 1-year incidence of people experiencing LBP ranges from 1.5%-36% and 6.3%-15.4%. \[14\] Patients who experience acute LBP are found to have a high prognosis, however studies have found recurrence is common for 33% of individuals within 12 months and within a population of approximately 20-40%, LBP will become persistent and disabling (chronic). \[14\] In 2015, the global prevalence of activity -limiting LBP was 7.3%, 540 million people were affected at any one time.\[11\] Some studies suggest that there are predisposing factors such as age, gender, weight, occupation and particularly, occupational-related musculoskeletal disorder/ repetitive strain injury. \[11\] \[14\] Occupational-induced LBP is estimated to cause 21.7 million Disability Adjusted Life Years (DALYs). \[15\] LBP is characterised by a range of biophysical, psychological and social dimensions. Individuals with LBP, particularly chronic, are known to experience poor sleep quality and health perception, worsened quality of life (QoL) and depressive symptoms. \[12\] Several studies and researchers have found that LBP results in fear-avoidance (i.e. kinesiophobia), \[8\] anxiety, catastrophising and as well as it being the biggest reason for leave and absenteeism at work, \[13\] \[14\] it also causes an overuse / strain of the healthcare systems, with approximately 68% of individuals visiting a physician over a year. \[13\] Biopsychosocial Theory\[edit \\| edit source\] The biopsychosocial theory and model is one of the fundamental theories within pain neuroscience education\[9\] and it as a intervention for chronic musculoskeletal disorders. It has been particularly vital in the transitioning and evolving beliefs of LBP. Previously, LBP was mainly understood from a biomedical approach which meant that clinicians held biomedically oriented beliefs and offered advice that promoted less activity and more time off work. \[16\] Research has since shown that such advice was interpreted by patients as indicating activity to be dangerous hence leading into factors such as fear-avoidance, catastrophising etc. \[12\] Through several research, over the past 15-20 years, clinicians have been encouraged to shift management of chronic musculoskeletal pain from a biomedical/biomechanical approach to the biopsychosocial, \[12\] as psychosocial factors play an important role within individuals who experience chronic pain and has an impact on their function and QoL. All the psychological attributes associated with LBP such as fear-avoidance, catastrophic thinking and familial & social stress (stress-pain cycle) can increase the risk of physical disability which manifests as reduced functional capacity, avoidance of usual activities including work as well as impaired societal and recreational participation. \[10\] A systematic review in 2021 by Siddall et al.\[8\] concluded that there was a major barrier to exercise in patients with chronic pain due to kinesiophobia. Patients with low knowledge on the neurophysiology display high kinesiophobia and ultimately, it has been found that high levels of kinesiophobia is associated with reduced exercise adherence and an increase in pain & disability, \[8\] hence why pain neuroscience education is useful, as it aims to increase an understanding of the biopsychosocial nature of pain and the adaptability of the body. \[9\] Related Evidence\[edit \\| edit source\] Clinician perspective\[edit \\| edit source\] A clinician’s perspective to a treatment would concern assessing the relevant outcome measure to determine the effectiveness from that treatment / intervention. In the context of PNE and LBP, the consensus amongst research is that pain, and disability are dominant outcome measures used and can be applied through different questionnaires to evaluate these outcomes. Other outcome measures used in research include psychosocial elements to them such as quality of life, self-efficacy, catastrophising and kinesiophobia. Outcome measures to evaluate the use of PNE on LBP\[edit \\| edit source\] Pain – VAS / NRS Disability – ODI / RMDQ QOL - EQ-5D Kinesiophobia – Tampa scale Catastrophising - pain catastrophizing scale PNE\[edit \\| edit source\] Systematic review evidence that investigated the effect PNE has on musculoskeletal and LBP in patients included studies that evaluated the effect of PNE as a stand alone intervention. 2 studies from Wood and Hendrick \[17\] and 5 studies from Louw et al.\[18\] contained information regarding PNE's individual effect. Results showed that no study was able significantly decrease pain and there was low to moderate evidence for improving disability in the short-term or at all in regards to given outcome measures in the reviews. \[17\] \[18\] Whilst PNE's effectiveness on physical attributes are not as applicable as a stand-alone intervention, PNE's stand-alone effect on psychosocial components shows promising evidence to support its use. Evidence suggests that PNE can improve other elements that can facilitate function such as kinesiophobia and illness perceptions. \[19\] However, limited evidence, although favourable, can't solely justify the individual application of PNE therefore future research needs to investigate this further. PNE and Physiotherapy\[edit \\| edit source\] Clinicians will often incorporate the application of PNE in alignment with usual physiotherapy care (manual therapy/exercise prescription) as to utilise a multi-modal approach when treating chronic back pain. \[20\] There is compelling evidence to support the use of PNE along with physiotherapy interventions to have short- term improvements on pain. Systematic review & meta analysis evidence looking at PNE and physiotherapy in the treatment of chronic low back pain found that there was low to moderate evidence in the short-term for pain. \[8\]\[17\] \[21\] Additional evidence also highlights its moderate effects on improving disability. \[18\]\[22\] A dose-effect relationship has also been implied for single PNE sessions, i.e. \> 60 minutes, 4 to 8 sessions, intervention duration for 7 to 12 weeks, and following a group-based approach.\[21\] Information in the mentioned evidence does not specify what type of physiotherapy intervention is superior to one another. However, emerging research has found propitious evidence to support PNE alongside motor control training (MCT) as its suggested to deliver more effective results in improving pain and disability compared to current best-evidence physiotherapy care. \[23\]\[24\] MCT has also shown better results compared to core stability exercise, \[25\], although this result was exclusive to women due to the population studied thus limiting its validity. With limited evidence, it is hard to distinguish which intervention format is more effective to combine with PNE and therefore warrants the need for further research to determine clear differences in the interventions. Updating current systematic evidence could help establish clearer findings. PNE and physiotherapy effect on psychological aspects of patients showed potential improvements to kinesiophobia and catstrophisation but improvements were negligible failing to demonstrated clinically meaningful changes. \[17\] Type of physiotherapy care used with PNE\[edit \\| edit source\] Manual therapy Exercise prescription Aquatic therapy Paced/Graded exposure Acupuncture/dry needling Motor control training Patient perspective\[edit \\| edit source\] A patient’s treatment perspective involves two main components: the patient’s views about their health (e.g. what the condition is, what its causes are and how serious it is to the patient) and the patient’s values (e.g. what will help them most and how this can be achieved). Patients values and beliefs\[edit \\| edit source\] Minimal research investigates the patient’s values in learning about their pain. However, a mixed-methods survey found that patients believed PNE was necessary for their improvement of persistent pain. \[26\] PNE as an intervention provides a coherent biological explanation for how emotions such as stress can initiate a hormonal response which can sensitise neural processes associated with pain.\[18\] Pain reconceptualisation helps manage stress and anxiety, limiting the pain induced by these emotions. Although there’s limited research in this area, the mixed-methods review provides contextualised insight into qualitative data on the research question, providing a foundation for refining PNE to focus on pain concepts deemed most valuable to people with pain and use patient-centred language to best communicate the concepts. A common belief that follows pain is the concept that pain means damage; therefore, learning that pain does not indicate bodily or tissue damage can help manage patients’ pain. \[26\] These findings are consistent with the fear-avoidance model, which describes how individuals may develop musculoskeletal pain due to avoidant behaviour based on fear. \[27\] When a patient is gradually exposed to fear situations, understanding fear-avoidance concept leads to less fear of injury and less avoidance of movement and behaviours. If a patient engages, pain may become less threatening, changing their priority from pain control to valued life goals, e.g., decreasing disability and kinesiophobia, through using positive connotations such as "understanding that even though it hurts, it is not a sign of damage". \[18\]\[28\] Education\[edit \\| edit source\] Teaching\[edit \\| edit source\] There is limited research which evaluates the most effective use of PNE. Typically, PNE sessions are delivered in fifteen-to-thirty-minute sessions once or twice a week for four to six weeks. \[29\] They aim to decrease inappropriate beliefs and maladaptive behaviours associated with their chronic pain experiences. Teaching is most effective if taught by an experienced clinician. \[30\] Delivery\[edit \\| edit source\] Patients should receive individualised instructions and sessions are primarily delivered as verbal one-to-one sessions; however, new research suggests that it is beneficial to promote and conduct PNE in a group-based setting. \[31\]. Group strategy can be a powerful tool in encouraging values such as group feelings, improving self-esteem, and increasing adherence to the individual strategy. For example, a consequence of chronic pain may be kinesiophobia (the fear of movement). Romm et al. \[31\] concluded that group-based interventions significantly affect kinesiophobia through biopsychosocial interventions and learning theories such as observational learning. Patient-Clinician Relationship\[edit \\| edit source\] To maximise the effectiveness of PNE, it is essential to build rapport with the patient. Research has shown that the patient-clinician relationship has a statistically significant effect on healthcare outcomes. \[32\]. Within the PNE intervention, the patient-clinician relationship is vital as the patient needs to trust and comply with the instructions given by the practitioner to aid their recovery. Future research\[edit \\| edit source\] There are still areas within PNE that need to be further researched. One shortcoming is the heterogeneity of studies as age range, gender, and education don’t tend to be considered. Bilterys et al. \[33\] found no clinically meaningful differences in the effectiveness of PNE between educational levels. However, this has minimal research and would be beneficial to further understand patient factors affecting PNE. Despite the evidence suggesting the positive benefits of PNE, the educational process and specific parameters that are key to improving patient outcomes are still unknown; furthermore, the therapist-patient interaction warrants further exploration when using educational components in the management of chronic pain. \[34\] Zimney et al. \[34\]propose behaviour change, optimising the learning environment and using an individualised multimodal approach when using the PNE programmes in the management of chronic pain. Clinical application of PNE\[edit \\| edit source\] One aspect of PNE within the literature with little controversy is that PNE produces the most favourable outcomes when used in conjunction with more 'traditional' physiotherapy treatments. Utilising the current literature, in particular a study from Louw et al., \[35\] we have outlined a strategy which clinicians can utilise to incorporate PNE into their practice. First session\[edit \\| edit source\] Within the first session, a comprehensive assessment of the patient will be completed. This is like a 'traditional physiotherapy assessment' as it gathers both subjective and objective information which the clinician can utilise to inform their diagnosis and treatment. We propose the first session should be split into 4 sections which should total to around 1 hour: Conversation/interview (~25-30mins): Initially clinicians should have a conversation with the patient where they predominantly listen to the patient, gathering information about their experiences, suffering and beliefs. This part should not be rushed, and adequate time is needed for the patient to tell their own story. Within this time the clinician can take note of any issues/beliefs which the patient mentions which may need to be addressed in later PNE sessions. Physical examination (~10 mins): It is important that significant pathologies are ruled out to ensure that there is no underlying sinister pathology. Physical examination will also give us objective markers that we can utilise to track the progress of individuals to see if treatment is effective. The results from this examination should be conveyed to the patient, with emphasis on the use of clinician language to avoid terms like “wear and tear” which have negative connotations. Introduction to PNE (~10-15mins): Depending on the time availability of the clinician following a thorough assessment, PNE can then be briefly introduced to the patient. A good way to start the conversation is asking “Has anyone explained to you why you are still experiencing pain?”. If the patient is interested in learning more this is when a brief metaphor can be used to start to explain the hyper sensitive nervous system which is contributing to their pain. A common metaphor used is an oversensitive alarm clock (described below), however there is a number of metaphors used within pain education and research has found that no individual story or metaphor is superior to another. \[36\] 'Tame the beast' by Lorimer Moseley is another popular metaphor which can be utilised by patients, one benefit to this metaphor is that it has a patient centred video which clinicians can signpost a patient to if they are short of time in the initial session. \[37\] 4. Exercise prescription (~10-15mins): As PNE is most effective when used in conjunction with other therapies, simple exercises should be given to the patient to encourage movement. The patient should perform the exercise during the session and the clinician should discuss the patients perception of the exercise, challenging any inaccurate beliefs utilising the PNE metaphor. Depending on the time available to the clinician this initial session may need to be split into two sessions, however the sessions should then be delivered within a short time frame of each other. The oversensitive alarm clock\[edit \\| edit source\] Normal response of nervous system To begin with we must explain to patients the complexity of the nervous system; there are more than 400 individual nerves which all connect like roads, if they were all combined and laid out they would cover more than 45 miles (ref).We can then explain how a healthy nervous system works, introducing the metaphor of an alarm clock: "When we step on a pin while barefoot we need to know about it so that we can remove the danger and take care of ourselves. The nervous system works like an alarm clock, sending a message to the brain producing pain so that we can take action such as removing the pin from our foot. The alarm will then calm down and is ready to warn you of any future danger such as stepping on another pin." Using illustrations will help to explain this metaphor. We can then apply this to the patients presenting problem. Response of a sensitive nervous system We can then explain to the patient that in approximately 1 in 4 people the alarm system does not calm down and stays extra sensitive: "Before you had the onset of pain the alarm clock had lots of space for activities before the alarm would be triggered but because it is very sensitive there is little room for activities before the alarm goes off. (That explains why your back hurts after standing up for 5 minutes.)" Again the use of an illustrations can help a patient to understand this. We can then round up the brief introduction by explaining that there is a lot of factors that are contributing to this hypersensitivity, which you can then discuss in later sessions. It is also important that you explain that there are strategies we can use to calm the alarm clock down to give the patient the reassurance that things will get better. "There are things that are making your alarm clock extra sensitive and also strategies we can use to help calm your alarm clock down. We can discuss these in your later sessions but the main thing is that we start to calm your alarm clock down to give you more room for activities." 'Homework'\[edit \\| edit source\] It is important that we encourage patients to take an active role in their own recovery. We should provide patients with the relevant tools to enable this and increase their self-efficacy. Giving patients a few simple tasks can help to promote this. These can include: Question Generation: Encourage the patient to write down any questions that they may have regarding pain and the PNE material covered in the session. This helps to remove doubts and increase their understanding of pain experiences. Encourage exercises: Exercise help to enhance movement and increase function. A focus on breathing and relaxation should be emphasised during the exercise with reference to PNE and relaxation of the hypersensitive nervous system. Aerobic exercise: Starting very small in an exercise of their own choice (walking, swimming, cycling, running etc.) patients should be encouraged to participate in aerobic exercise. The benefits should be explained to the patient in terms of the down regulation of the sensitised nervous system. Set goals: Patient should be encouraged to list 5 goals they wish to achieve prior to the next session. Asking the patient “If you could flip a switch and get rid of all your pain, what would you do again?” Clinicians should use their own judgement when giving patient tasks to complete at home, some proactive patients will complete all tasks before the next session, while those with low self efficacy may be overwhelmed when given a large number of tasks. One way to combat this is to give patient 1-2 tasks at a time, a clinician should use their own judgement to determine the tasks to prescribe and what tasks can be introduced in later sessions. Subsequent sessions\[edit \\| edit source\] Subsequent session should be individualised to patients and their journey with PNE. The content of these sessions are dependent on what was covered in the previous session e.g. if there was not time in the last session to discuss the importance of aerobic exercise or to teach the patients relaxed breathing techniques then this could be a priority for the next session. A useful structure for later PNE could be: Question and answer: Discuss any questions the patient had about the previous session. If patients do not have any questions the clinician could ask the patient about what they understood from the previous session, this can help identify any areas which patients were unsure of or had forgotten which can then be revisited. Progress PNE: New metaphors, pictures or information can be discussed with the patient. These should be relevant to the patients experience or findings. Review goals: Break the patients goals down into SMART goals. This encourages pacing and graded exposure which can help to motivate patients throughout their journey. Each session the goals should be reviewed, and patient should be encouraged to progress to the next stage if appropriate. Traditional therapy: The clinician should use their own clinical judgement to determine if the patient would benefit from other treatments such as manual therapy. The exercises from previous session should be reviewed and new exercises prescribed to encourage increase function.](https://www.physio-pedia.com/Pain_Neuroscience_Education_\(PNE\)_for_Low_Back_Pain?utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal) [Telehealth for Low Back Pain - Physiopedia Introduction Telehealth is defined as the provision of healthcare remotely through the form of telecommunications, such as telephones or laptops. The primary aim of Telehealth is to improve patient's health through education and service provision while reducing healthcare costs and overcoming geographical barriers \[1\]\[2\]. Telehealth in other conditions has promoted adherence. A study on hospital readmittance reported that 49% of participants who received Telehealth were likely to be readmitted to the hospital compared with 67% of those who did not receive the Telehealth treatment \[3\]. In other areas such as Psychology, there is evidence that using video to carry out assessment can work well though there are limitations that can create inaccuracies, including feeling distant to patients and that some patients may not be able to use technology well \[4\]. What is Telehealth?\[edit \\| edit source\] Figure 1: Video consultation Telehealth is a modality in which a healthcare professional such as a Physiotherapist, Nurse, or Doctor can consult with a patient through video or audio call utilizing a telephone, laptop, mobile phone, or tablet. Telehealth is a term which is used interchangeably with ‘telemed,’ ‘telemedicine,’ ‘telerehabilitation,’ ‘physiodirect,’ and ‘teleconsultation.’ Ultimately, this service allows a healthcare professional and a patient to consult when they are not able to gather face to face for a variance of reasons \[5\]. As technology has progressed, the feasibility for Telehealth has progressed too, resulting in some cross-disciplinary behavior theories and models being used to guide the implementation of Telehealth \[6\]. These behavior theories help clinicians to understand the patient’s motivation, efficacy, and goals, and allow the clinician to deliver telehealth interventions that meet the patient’s individual needs, complement the patient’s behavior and characteristics, and suits the patient’s unique social environment \[7\]. The two primary underlying theories that underpin Telehealth are the self-determination theory and the self-efficacy theory \[8\]\[9\]. The self-determination theory has been used in health behavior intervention by identifying an individual's motivational blocks and distinguishing between autonomous and controlled motivations \[8\]. This theory identifies that incorporating engagement, usability, and acceptance helps to improve self-motivation and engagement in Telehealth \[10\]. When there is a low initial motivation to use Telehealth, it is vitally important to evaluate the delivery and ensure individual training and education to increase motivation to engage with telehealth services \[10\]. From this, the concept of self-efficacy and one's ability to meet the challenges of self-management and succeed directly impacts Telehealth. Within low back pain patients, self-management is particularly essential. Barriers to self-efficacy include health literacy access and support, which Telehealth directly provides solutions for, thus increasing the patient’s belief and motivation to work towards a successful recovery \[11\]. History of Telehealth\[edit \\| edit source\] Figure 2\[5\] Reasons for Teleconsultations. The term Telehealth originated in the mid-20th century when healthcare professionals would attend to infectious disease patients from a distance using bells and signs. In the 1970s Telehealth developed into what we know it to be today. Initially, NASA needed to solve being able to monitor astronaut’s health while in space. There developed Telehealth through means of video calls. In the 1980s militants on large vessels and workers on oil rigs in the surroundings of the USA would consult with healthcare professionals at the LA medical center through telephone and video call. As it was unrealistic for them to see someone face to face, Telehealth became their best option to get immediate advice. Fast forward to the 1990s, the USA become the largest consumer of telephone consultations, surpassing Norway. In 1996, figure (2) demonstrates what areas these types of consultations were being used for \[5\]. Validity and Reliability of Telehealth in Physiotherapy\[edit \\| edit source\] Validity is the ability of a measure or modality to achieve what it is intended to achieve. When a modality has high validity, the results can be more trusted or believed \[12\]. A randomised control trial conducted in 2014 investigated the validity of Telehealth in lower back pain compared to face-to-face appointments. It found that Telehealth’s validity was varied dependant on the specific element of the assessment, as shown below: Specific Validity Element Telehealth Validity Detection of pain with specific movements High validity Identifying the quality lumbar movement Moderate validity Postural analysis Poor validity Identifying reasons for limitations Poor validity The study concludes that ‘Important components of the standard musculoskeletal assessment of LBP are valid via telerehabilitation in a clinical setting.’ \[13\] Reliability is the ability of a measure or modality to achieve the same results when the measure is repeated \[12\] \[14\]. Specific Reliability Element Telehealth Reliability Inter-rater reliability 0.92-0.96 very good Intra-rater reliability 0.92-0.96 very good Telehealth as a Tool for Assessing Low Back Pain\[edit \\| edit source\] Telehealth can be and has been used in the assessment and management of Low Back Pain recently\[15\]. There are certain critical aspects of Telehealth that drive success in this area, including that it can encourage early intervention, patient participation, and good communication between clinician and patient \[3\]. Tools for Assessments\[edit \\| edit source\] The main tools used to perform Telehealth assessments and managements are mobile or device applications, websites, online chats or group discussions, email discussions, phone calls, or a combination of a number of these \[16\]. Telehealth has been commonly used in remote populations as these do not have easy access to clinics \[17\]. A 2014 study was investigating whether Telerehabilitation is a viable alternative to face-face assessment for patients with low back pain. Twenty-six participants were involved. The study found that there was an agreement in both approaches to identifying pain eliciting movements but poor agreement in identifying reasons for limitation in movement \[17\]. There have been several trials investigating the cost-effectiveness of Telehealth triage \[18\]. One such study investigating the use of Telehealth when implementing the McKenzie method for assessing and managing low back pain found Telehealth was significantly more clinically effective, and approximately 50% more cost-effective than the clinical based McKenzie treatment \[16\]. The main challenge facing the implementation of Telehealth is the limited existence of effective internet service facilities, and the initial engagement from patients is dependant on the adequate technological literacy of the patients \[19\]. Another way in which Telehealth aids in assessments is in its use in remote monitoring. Devices can collect physiological data from a distance and rapidly transfer that data to the patient’s cardiologist. Hospitals can have semi-autonomous monitoring of selected patients without the need for nurses to go over to the patient, leading to a 40% reduction in admissions and a significant drop in cost \[3\]. A new musculoskeletal assessment framework published in Cureus provides pre-consultation guidance and step-by-step remote examination instructions to musculoskeletal clinicians working in primary care to adapt their assessments based on published evidence, and community-sourced best practice; it also includes patient and clinician resources (patient information leaflet and photographs of examinations)\[20\]\[21\]. To learn more click on this link: Remote Musculoskeletal Assessment Framework: A Guide for Primary Care Future Improvements to Telehealth Assessments\[edit \\| edit source\] The majority of Telehealth facilities are implemented in areas where geographical location greatly restricts the patient’s ability to attend face-to-face consultations. However, very little research has been conducted in metropolitan cities, such as in the UK, where the population is not so sparsely populated. Hence it would be good to see more work carried out in the UK. Furthermore, the majority of the assessment techniques used by clinicians for investigating low back pain are designed for face-to-face environments. This reduces the same assessment techniques reliability when completed in a telehealth setting. More research into the adaption of these techniques into Telehealth appropriate ones, as well as trials to see whether these are effective is needed. There have not been any published studies showing how carrying out a subjective assessment would work using TeleHealth. This is a concern with the patient’s safety and data security affected if a subjective assessment is not entirely feasible within Telehealth. Still, further research needs to be carried out to assess more closely the economic benefits to Telehealth \[18\], as well as further advancements in technology to increase the accuracy of telehealth assessment consultation, as even with video consultations, the prefered form of Telehealth for assessing posture, it can still be challenging to discriminate physical landmarks on a video call \[22\]. Using Telehealth is a good alternative, but more work needs to be done to improve postural assessments, and further research is needed to see how devices utilising remote monitoring can be applied to LBP patients. Telehealth as a Tool for Management Low Back Pain\[edit \\| edit source\] With the advancements of online technology websites and applications have created a new frontier for research into patient’s self-managing their own physical conditions in their home environments. As compliance research shows that between 45-70% of patients are noncompliant with their physiotherapy prescriptions, This new field of Telehealth management promises to increase patient exercise adherence while offering physiotherapists a method to support patient self-management between face-to-face sessions \[23\]. The current practice guidelines for managing low back pain can be broken into three major categories: patient education, behavioral therapy, exercise prescription \[24\]. All of these could be delivered through telehealth rehabilitation \[25\]\[15\]. Telehealth is a beneficial intervention, with the best outcomes, in trials investigating walking programs, cognitive-behavioral therapies, education, and group therapy sessions. A systematic review of 11 Randomised Controlled Trials has been conducted with a total of 2,280 participants looking to evaluate whether interventions delivered by Telehealth improve pain, disability, function, and quality of life in Non-Specific Low Back Pain \[26\]. The Telehealth interventions in the studies were delivered by telephone and online chats, websites, and emails. An important finding in the study was that those who participated in a tailored self-management web-based program involving education and behavior strategies were near two times less likely to experience LBP symptoms again two months after treatment (1.7 OR) \[26\]. Despite this, the only outcome that a significant difference favoring the use of Telehealth was quality of life. The results showed no significant improvement in pain or disability short term in any of the studies (WMD -2.61, 95% CI -5.23-0.01). There was no significant difference in disability. Another randomized controlled trial investigating the effect a telehealth-based mobile application called Snapcare could have on chronic low back pain patient's pain and function. Of the 93 participants recruited, 45 received Snapcare in addition to a written prescription, and 48 received medicine and recommended physical exercise. The was a significant (P\<0.05) reduction in pain and disability in both groups, and a significantly (P\<0.001) greater decline in the Snapcare group compared to the control group \[27\]. The conclusion is that the telehealth application reminded and promoted the patients to be compliant with their physical activity program, thus facilitating the patient’s recovery by aiding the increase in physical activity. Within the management of low back pain empowering the patient to feel able to self-manage effectively is vitally important to treatment success. Trials investigating the role of Telehealth as a unique intervention in the management of acute low back pain found an educational component that improves the patient’s knowledge of their condition and encourages an active lifestyle, as well as health tracking devices, such as a pedometer, is successful in reducing current pain intensity, depression, anxiety, stress, and duration of pain significantly (P=0.04) \[28\]\[29\]. Implementing behavioral change approaches such as cognitive behavioral therapy and health coaching principles can be used successfully within Telehealth as well. Compared to usual care alone, combining telehealth strategies with usual care has a clinically significant reduction of pain, disability, and function in patients with subacute low back pain both short and medium-term \[30\]\[31\], There is conflicting evidence on the effect Telehealth has on chronic low back pain, with moderate-quality evidence reporting there is no significant difference between Telehealth and minimal interventions for reducing short term or medium term pain in chronic low back pain patients \[30\]. Some trials have found that Telehealth does not affect chronic low back pain patient's function short or medium term, as a sole intervention or combined with the minimal intervention \[31\]. However, when trials investigated telehealth effect on patient's quality of life, Telehealth was significantly superior in improving all patients' quality of life irrespective of the duration of low back pain symptoms or length of follow-up \[26\]. For chronic low back pain, Telehealth seems to be suitable when needed but not yet as an undisputed good alternative to face-to-face appointments. Management Options\[edit \\| edit source\] The three main Telehealth models for Physical Therapy are \[32\]: Live Video (Synchronous): This uses real-time live consultation to treat patients. Store and Forward (Asynchronous): This uses the secure transmission of pre-recorded materials to treat patients. Remote Patient Monitoring: This uses technology to remotely get medical data on the patient’s treatment progress. The various methods of telehealth attempt to comply with all three of these models to ensure the treatment provided are of the best quality, and accessible for all patients. For example, Reflexion Health Inc has developed a telehealth tool called VERA System, which combines all three Telehealth models. It walks patients through exercises, carries out an accurate analysis of movements, and gives real-time feedback. Though not used for treating LBP, it was shown to be of equal benefit as traditional physical therapy in Post Total Knee Replacements Rehab, with the additional benefits of having significantly lower health costs \[33\]. Future Improvements to Telehealth Managements\[edit \\| edit source\] A major issue affecting the development of Telehealth is that it is as good as the technology is the most available technologies, such as SMS, Apps and Health Trackers, are the least investigated. These have shown some promise in some papers but not specifically enough with LBP. Therefore more research needs to be done to investigate the effects of app-based interventions and fitness trackers especially \[3\]\[27\]. Also, as more technology has been developed specifically for health purposes, not many quality technologies exist that are transferable to physical therapy. Those that do exist require further testing to know their full clinical benefit. As video calls are the most frequently used telehealth tool more research into whether face to face video management enhances LBP management is required to support its use. There is also a need to investigate multimodal interventions within Telehealth, as the majority of telehealth methods attempt to incorporate the three main models. Trials investigating the relative success of these three models are needed. As with assessment methodology, there is no specific management option with Telehealth and a lot of the studies investigated use such different means it is difficult to come to a clear conclusion \[26\]. Confounded upon this is the disagreement within the literature for managing low back pain using Telehealth, with most of the current telehealth-based interventions showing no significant clinically important benefits in the outcomes investigated, particularly for chronic Low back pain. In contrast, research on acute or subacute low back pain has shown promising significantly important benefits in the outcomes measured. The significant benefits Telehealth has on all types of low back pain patient's quality of life, suggests that there is biopsychosocial benefits telehealth has on low back pain patients and demands further study. Telehealth Pros and Cons\[edit \\| edit source\] Within Telehealth, there are several pros et contras. One study investigating the use of a Telehealth based website to facilitate health coaching found that participants logged into the website only 38% of the recommended time \[34\]. Showing that adherence and compliance to the telehealth interventions were lower than recommended or expected. Within this study, there are some possible explanations to why the adherence to the telehealth treatment was lower than expected. Potentially the patients were becoming disheartened and disinterested as the effects of the treatment on their low back pain were smaller than they might have expected. Also, the technology itself may have been limited and a factor contributing to the higher level of non-compliance than expected. Below is a break down of the most common advantages and disadvantages that Telehealth offers to physiotherapy, particularly in the management of low back pain. Pros Cons Telehealth provides an alternative solution for people who live in remote areas and are not always able to travel. Poor patient compliance is associated with using telehealth \[35\]. Telehealth makes healthcare accessible to everyone, as long as there is an internet connection, even during a global pandemic like 2020. Patients often decline to use Telehealth due to preferring face to face contact. Telehealth provides a means to use new technology to enhance health services \[26\]. May lead to fragmentation of care amongst multiple providers. Telehealth is effective in managing health conditions such as obesity and asthma. There may be a lower quality of the patient-clinician relationship Telehealth reduces healthcare costs by improving efficiency and revenue. Patients may have a lack of access to the necessary technology. Telehealth offers a better possibility of continuity of care. There is a high initial cost of acquiring the technical equipment. Telehealth can ease the global burden of low back pain, which has a high prevalence rate of 39% worldwide \[36\]. Many argue its overall effectiveness for dealing with chronic Low Back Pain is limited. Telehealth has been shown to significantly improve patients quality of life, particularly patients with chronic low back pain. Telehealth may be detrimental to clinicians establishing patient rapport. Patients had increased compliance with their treatment exercises \[27\]. Conclusion\[edit \\| edit source\] Telehealth has very high validity and reliability suggesting there is a clinical use. From a moderate amount of research, there is some benefit to using Telehealth to manage patients with low back pain, but there is still a need for more research. Within physiotherapy telehealth is a relatively new area of study, still requiring the development and testing of specific assessment and management approaches to treating certain conditions. Within telehealth research, the patient satisfaction scores and patient quality of life scores are significantly higher within telehealth interventions groups. Despite this, there is still a public concern associated with Telehealth. Many patients may not fully understand the breadth of physiotherapy and what is included within physiotherapy treatment, assuming that physiotherapy requires physical contact. With the COVID-19 pandemic, telehealth has played an essential role in enabling physiotherapy clinics to continue semi-functioning during global lockdowns. Telehealth has enabled infections to be avoided while still maintaining contact with patients ensuring exercises are being adhered to. There is a vital role Telehealth plays in sparsely populated communities where the distance between clinical facilities and patients is too great or dangerous for either patient or clinician to traves. The research has shown that Telehealth can be an effective supplement to usual physiotherapy, rather than a replacement. The future of Telehealth seems promising, with the continual developments and improvements of current technologies, hopefully, followed by more researcher, from all areas of the world, taking an active interest in Telehealth biopsychosocial, hygienic, and economic benefits. Consequently, further clinical trials and systematic reviews will be carried out broadening and deepening the pool of research to base the management of low back pain using Telehealth.](https://www.physio-pedia.com/Telehealth_for_Low_Back_Pain?utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal) [Fitness and Low Back Pain - Physiopedia Introduction Low back pain (LBP) is an umbrella of conditions with 80% of adults estimated to experience LBP at some point during their life \[1\]. Low back pain refers to pain between the bottom of the ribs and the buttock crease. A high physical fitness level, and especially muscle endurance in the back muscles, is associated with lower risk of back pain\[2\] A harmful misconception is that exercise should be avoided when LPB is present. Understandably, many patients are reluctant to exercise out of the fear that any exercises or stretching will aggravate their existing back pain. They may become reluctant to exercise and rely on medications.\[3\] Physical activity (PA) to increase aerobic capacity and muscular strength, especially of the lumbar extensor muscles, is important for patients with chronic LBP in assisting them to complete activities of daily living.\[4\] This article focuses on non specific chronic low back pain (NSCLBP) and its relations with fitness. Fitness \[edit \\| edit source\] Plank exercise, core activation Physical fitness is a set of attributes that people have or achieve. Being physically fit has been defined as the ability to carry out daily tasks with vigour and alertness, without undue fatigue and with ample energy to enjoy leisure-time pursuits and meet unforeseen emergencies\[5\] Being physically fit depends on how well a person fulfils each of the components of being healthy.When it comes to fitness, these components are\[6\]: Cardiorespiratory Endurance - VO2 max per Kg of body mass \[7\] Muscular Endurance - Currently no Gold Standard measurement for muscular endurance Muscular Strength - There are a number of ways to measure muscular strength. The Biering-Sorenson Test. is an easy to perform test for back strength. Isokinetic Dynamometry is the gold standard re back strength but is very expensive. \[8\] Body Composition:- The current Gold Standard is a Four-Compartment model of measurements most commonly consisting of Mass, Total Body Volume, Total Body Water and Bone Mineral Content.\[9\] Flexibility - Optical Gold Standards such as the Vicon Motion Tracking System\[10\] The following sections will look at each of these components individually, relating it to LBP. Cardiorespiratory Endurance\[edit \\| edit source\] Cardiorespiratory endurance indicates how well the body can supply fuel during physical activity via the body’s circulatory and respiratory systems. Aerobic activities that help improve cardiorespiratory endurance are those that cause an elevated heart rate for a sustained period of time. eg swimming, brisk walking, jogging, cycling\[6\] LPB relevance Aerobic exercise increases the blood flow and nutrients to the soft tissues, including those in the back, hastening the the healing process. Thirty minutes of aerobic exercise increases the body’s production of endorphins, a natural alternative for pain relief for the body. This helps with clients pain levels and may reduce reliance on medication for pain. A low aerobic fitness level is associated with CLBP Maximum oxygen consumption (VO2max) is found to be significantly lower by 10 mL/kg in men and by 5.6 mL/kg in women with CLBP compared to men/women without.\[3\] Muscular Endurance \[edit \\| edit source\] Biering-Sorenson Test Fitness also includes muscular endurance, which is the ability of a muscle to continue exerting force without tiring.\[6\] Patients with low back pain have reduced lumbar extensor muscular endurance in comparison with non-sufferers.\[11\] \[12\]See Biering-Sorenson Test. Abdominal muscular endurance in low back pain sufferers is significantly decreased in contrast to those in the normal health population \[13\] Lumbar fatigue as a result of low muscular endurance has been shown to reduce the person’s ability to sense the positioning of the lumbar spine. People with chronic LBP have impaired ability in controlling the position of the lumbar spine after a fatiguing task, leading to lumbar instability.\[14\] Patients with lower back pain, have a higher percentage of fast type I glycolytic fibres compared to the slow oxidative fibres. Fast twitch fibers contract quickly but get tired quickly, rendering them less resistant to fatigue. This makes these people more susceptible to back injury. Non-LBP people have a much higher percentage of slow twitch fibers, which are best for endurance work, as they can carry out tasks without getting tired, and are present in core muscles.\[15\]\[6\] Strength and Low Back Pain\[edit \\| edit source\] Back extensors at work. The core is the group of trunk and hip muscles that surround the spine, abdominal viscera and hip. Core muscles are essential for proper load balance within the spine, pelvis, and kinetic chain. Core strengthening\[16\] has a strong theoretical basis in treatment and prevention of LBP, as well as other musculoskeletal afflictions. A reduction in core strength can lead to lumbar instability.\[3\] Muscle strengthening exercises form part of the NICE treatment guidelines for Early management of persistent non-specific low back pain. The importance of the core relate to its function ie sparing the spine from excessive load and transfer force from the lower body to the upper body and vice versa. Having a strong, stable core helps us to prevent injuries and allows us to perform at our best. In order to protect the back, ideally we want to create 360 degrees of stiffness around the spine as we move, run, jump, throw, lift objects and transfer force throughout our body. We do this when all of the muscles in our hips, torso and shoulders work together\[17\] Exercises to activate the deep abdominal muscles including the superficial muscles, transversus abdominis muscle and the multifidus are important for CLBP patients\[3\]. Measures of Back Strength: For information here look at Physiotherapy Assessment section of Core Stability Few of us will have access to a isokinetic machine to measure trunk strength, as shown in video below. \[18\] Body Composition \[edit \\| edit source\] Obesity can lead to altered body positions eg exaggerated lumbar lordosis The body is composed of water, protein, minerals, and fat. A person can potentially maintain the same weight but radically change the ratio of each of the components that make up their body. A two-component model of body composition divides the body into a fat component and fat-free component. Body fat (storage fat) in excess can increase susceptibility to chronic illness, health complications, and LBP. Numerous studies have been conducted highlighting the relationship between increased fat content and the likelihood/prevalence of lower back pain. A study conducted in 2003 \[19\] found that there was a moderate positive relationship between obesity and lower back pain, however the results were based on the BMI calculation which does not definitively measure body fat content. In a study conducted by Urquhart 2011 which took into account the amount of body storage fat\[20\] and it was evident that there was a relationship between obesity and lower back pain An increase in body weight alters spinal biomechanics and loading, creating excess strain to be put through certain structures eg Obesity can lead to altered body positions such as exaggerated lumbar lordosis which will cause an alteration in spinal loading mechanics. Flexibility\[edit \\| edit source\] Flexibility refers to the range of movement across a joint. Flexibility is important because it improves the ability of the kinetic chain to work smoothly and can help prevent injuries. It is specific to each joint and depends on a number of variables, including the tightness of ligaments and tendons. Stretching Relevance to CLBP Stretching the soft tissues in the trunk and lower limb eg Back and thigh muscles and the regions ligaments and tendons. This can help to mobilize the spine, and improve the range of motion of the spine, decreasing back pain. Stretching exercises decrease the muscle stiffness as a result of changes in viscoelastic properties, due to the decreased actin-myosin cross-bridges and the reflex muscle inhibition.\[3\] Improved range of motion assists in the spine and related areas improves the ability to complete ADLs eg lifting and bending which require trunk flexion, a complex interaction combining lumbar and hip motion\[3\]. Spasmodic or shortened back muscles adversely affect the complex spinal mechanics \[21\]. Tightness in the hip flexors and hamstrings can lead to a Lumbar hyperlordosis, predisposing patients to lumbar facet syndrome\[22\] Exercises to Decrease Low Back Pain\[edit \\| edit source\] It has been showed by numerous studies that exercise therapy decrease low back pain and improve overall functional mobility. Here are some methods which help to decrease low back pain. Aerobic exercise\[edit \\| edit source\] Aerobic exercise increases the blood flow and nutrients to the soft tissues, including those in the back, hastening the healing process. low impact exercise elevates the heart rate without worsening the back pain. Exercise like walking or cycling help to improve circulation, strengthen the muscle of legs and back, reducing the stiffness and pain in the back. swimming is another great aerobic exercise that improve cardiovascular endurance, a full body workout which improve flexibility and muscular endurance. Stretching and Strengthen Exercise\[edit \\| edit source\] postural exercises have improved pain control and improve functional mobility on low back patient. Knee to Chest Stretch Bridges Exercise Cat and Cow Stretch Seated Lower Back Rotational Stretch lumbar rotation In acute low‐back pain, exercise therapy is as effective as either no treatment or other conservative treatments.\[23\] Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low‐back pain, particularly in healthcare populations.\[23\] Conclusions\[edit \\| edit source\] Importance of Fitness A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain concluded thus: A general exercise programme that combines muscular strength, flexibility and aerobic fitness is beneficial for rehabilitation of non-specific chronic low back pain. Increasing core muscular strength can assist in supporting the lumbar spine. Improving the flexibility of the muscle-tendons and ligaments in the back increases the range of motion and assists with the patient’s functional movement. Aerobic exercise increases the blood flow and nutrients to the soft tissues in the back, improving the healing process and reducing stiffness that can result in back pain.\[3\] And remember the important message is that embarking on any regular exercise will be of benefit to an overall person’s health including reducing back pain. With exercise they will look and feel better.\[6\]](https://www.physio-pedia.com/Fitness_and_Low_Back_Pain?utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal) [Aquatic Therapy in the Management of Chronic Low Back Pain - Physiopedia Introduction Chronic low back pain (CLBP) is a very prevalent condition, affecting millions of people worldwide.\[1\] It is also one of the leading causes of disability. \[2\] Aquatic therapy is a popular treatment modality for those with musculoskeletal and neurological conditions due to the unique properties of water which confer benefits. \[3\] Both of these topics are covered separately on Physiopedia pages but have yet to be combined in one page. This page aims to present the research so clinicians can be more informed and potentially offer aquatic therapy as a treatment modality for those with CLBP. Low Back Pain Classification by Duration:\[edit \\| edit source\] Acute low back pain: 6 weeks or less Sub-acute low back pain: 7-12 weeks Chronic low back pain: More than 12 weeks \[4\] Chronic Low Back Pain\[edit \\| edit source\] Chronic low back pain refers to pain persisting for longer than three months, even after the initial injury or underlying cause of acute low back pain has been treated. \[5\]\[6\] There are two further classifications: Non-specific Low Back Pain is defined as "pain, tension, soreness and/or stiffness in the low back region between the lower margin of the 12th rib and the gluteal folds which is not attributed to any recognisable pathology". \[7\] Non-specific low back pain affects approximately 90% of all patients with low back pain. \[8\] Specific Low Back Pain, these pathologies can be classified as followed: \[9\] Disc herniation Spondylolisthesis Lumbar muscles or spinal ligament strain/ sprain Scoliosis Osteoporosis Ankylosing spondylitis Cauda equina syndrome Scheuerman's Kyphosis Epidemiology\[edit \\| edit source\] Image 1: Age distribution of chronic low back pain from 2008 to 2018 in United Kingdom (World Bank, 2020)\[10\] Low back pain (LBP) affects approximately 7.5% of the global population (577.0 million people) of those, 5-10% of all LBP patients will develop CLBP. \[11\] Specifically, in the United Kingdom, this accounts for 1/3 of all adults and is the leading cause of disability. \[12\] In all age groups, the prevalence and number of people living with LBP has continually increased between 1990 to 2017. \[13\] Even though the prevalence of LBP increases with older age, the greatest number of people with LBP are currently in the 50 to 54 year-old age group. \[13\] CLBP is more common in women, those of lower socioeconomic level, people with lower education status, and smokers. The incidence appears to have increased over time. This might be due to significant changes in lifestyle and work environment.\[14\] A family history of severe back pain, radiating pain, recommendation to rest after a back pain consultation, occupational LBP, or LBP caused by a traffic accident are all linked to chronic disabling back pain over the course of a lifetime. \[15\] The development of CLBP is also influenced by job satisfaction and psychological variables. Anatomical Relevance\[edit \\| edit source\] Lumbar Lordosis The lumbar spine consists of five lumbar vertebrae (L1-L5). The vertebrae form a slightly inward curve known as lordosis. These vertebrae are connected by facet joints; which allow for lumbar flexion, extension, rotation and lateral rotation.\[16\] Lumbar Spine Pathology\[edit \\| edit source\] The lumbar spine's two lowest segments, L5-S1 and L4-L5, bear the greatest weight and move the most, rendering them vulnerable to injury. In between the vertebral bodies, are the intervertebral discs that provide flexibility to the spine, maintaining the height between the vertebrae and distribute compressive loads by acting as shock absorber. As a result of aging, the discs may become less flexible and dehydrated, thus more prone to tearing. \[17\] This makes them more likely to herniate or degenerate which can cause pain in the low back. Studies also found many patient with CLBP has disc degeneration. \[18\] The lumbar region also contains large muscles that support the back and allow for movement in the trunk of the body when working together with the abdominal, the gluteal and the leg muscles. These muscles can strain or spasm which is also another common cause of low back pain. \[19\] Pathological changes\[edit \\| edit source\] Some studies suggests that para-spinal and multifidus muscle groups are significantly smaller in patients with CLBP than in healthy patients.\[20\] They believe, patients with persistent unilateral LBP, that this will present on the symptomatic side. \[21\] These finding can further explain in 2 aspects (Microscopic \[22\] and Macroscopic \[22\]). Microscopic change\[edit \\| edit source\] It has been reported that patient with severe CLBP have a higher portion of type IIB muscle fibre (fast twitch glycolytic) at the expense of type I muscle fibre (slow twitch oxidative). \[23\] In healthy population, the paraspinal muscles have been found to have more type I muscle fibre in comparison with other skeletal muscle. The alteration in fibre type in severe CLBP, could lead to lowered fatigue resistance of the paraspinal muscles which will result in higher vulnerability of the lumbar spine and cause pain.\[24\] Macroscopic change\[edit \\| edit source\] CLBP can affect muscle structure by compromising muscle function. Comprised muscle function due to pain can alter muscle structure, including reduce muscle cross section and increase fat infiltration.\[25\] Pain-related nerve inhibition reduces lumbar muscle activity in order to prevent tissue damage and lead to muscle inhibition and atrophy. Clinical Presentation\[edit \\| edit source\] Dull and achy pain that is contained to the low back region Worsening pain after prolonged sitting or standing Muscle spasms and tightness in the pelvis, low back and hips Burning and "electrical shock" like pain that radiates from the low back to the back of the thighs and/ or the lower extremities Difficulty standing up straight, bending and walking \[26\] Prognostic Indicators\[edit \\| edit source\] The importance of prognostic factors\[edit \\| edit source\] By determining which variables are prognostic outcomes, clinicians gain insight on the biology and natural of the disease Appropriate treatment strategies may be optimised based on the prognostic factor Prognostic factors are often used in the design, conduct and analysis of clinical trials Patient and their families are informed about the risk of recurrence or future development of the disease \[27\] Prognostic indicators for poor outcomes in CLBP\[edit \\| edit source\] \*If odds ratio\> 1: odds of exposure among cases is greater than among controls (a positive association between disease and exposure) \[28\] Table 1. Examples of predictor factor of CLBP and related clinical evidence. Working status (Active/ not working) Types of work The physical intensity of work, especially strenuous physical work, working in difficult working positions and carrying heavy loads was related to higher chronicity. \[29\] \[30\]\[31\] In a case-crossovers study with 12-months follow up, the carrying of heavy loads was predictive for CLBP with an Odds ratio of 8.0 (95% CI 2.8-22.6). \[32\] Smoking Smoking has been prove to be major predictor of the chronicity of CLBP. Odd ratio for smoking varied between 2.49 (95% CI 1.15-5.40)and 4.41 (95% CI 1.50-12.95) which showed positive correlation. \[33\] Obesity Positive correlation between obesity and chronicity of CLBP. The odd ratio differed between 1.075 (95% CI 1.023-1.128) and 1.21 (95% CI 1.04-1.41) in women and between 1.091 (95% CI 1.027-1.158) and 1.16 (95% CI 1.05-1.29) which showed there are positive correlation. \[31\]\[34\] Referred leg pain (yes/ no) LBP with any leg pain tended to be more severe than local LBP only, regardless of how severity was measured, and was also associated with higher frequencies of psychological risk factors. \[35\] Maladaptive psychosocial factors Depression was the most studied factor in predicting chronicity. Henschke et al.\[36\] and Shaw et al. \[33\]reported statistically significant positive relationship between depression and the chronicity of LBP. Main prognostic indicators for the disability of CLBP\[edit \\| edit source\] In a cohort study (n=1760) aiming to identify clinically important prognostic factors of disability in CLBP, younger age, less disability at baseline, shorter duration of back complaints at baseline, and higher baseline scores on the SF-36 Physical component Summary and Mental Component Summery were reported as predictors of absolute recovery (Quebec Back Pain Disability Scale score ≤20 points) at both 5- and 12-month follow-ups. \[37\] Main prognostic indicators for the chronicity of CLBP\[edit \\| edit source\] A recent systematic review of 25 studies reported that high pain intensity, carrying heavy loads at work, higher body weight and depression were the most frequently observed risk factors for CLBP. Maladaptive behaviour strategies, general anxiety, functional limitation during the episode, smoking, and particularly physical work were also explicitly predictive of chronicity. \[38\] Aquatic Therapy\[edit \\| edit source\] What is Aquatic Therapy?\[edit \\| edit source\] Group Aquatic Therapy Session Aquatic therapy can be defined as “A physiotherapy programme utilising the properties of water, designed by a suitably qualified physiotherapist”.\[39\] This treatment method involves various exercises in water which should be carried out by appropriately trained therapists in a heated, purpose-built hydrotherapy pool. The use of aquatic therapy is popular amongst patients with musculoskeletal and neurological disorders. \[3\] Patients report benefits of increased strength, flexibility, mobility, as well as decreased pain levels.\[40\]. These benefits are resultant of the unique properties of water, and therefore cannot always be replicated through land-based exercise. Unique Properties of Water\[edit \\| edit source\] Water Density\[edit \\| edit source\] The water density counterbalances the effect of gravity which allows the human body to float. This buoyancy effect offers support allowing less impact on joints. This is valuable during rehabilitation as it allows patients who are experiencing pain, to exercise with reduced loading through the joints. Additionally, this buoyancy effect controls the downwards movement of the body and therefore decreases the need for eccentric control. \[41\] Exercises such as walking, jogging, or running which may be painful to patients, can now be performed in water with less impact on the joint and therefore less pain. For spinal patients this causes reduced axial loading and joint stress on the spine. Natural Resistance of Water\[edit \\| edit source\] Water has a natural resistance as a result of its density and viscosity. This allows for effective strengthening during rehabilitation treatment sessions. The intensity of the resistance can be manipulated as well to fit the individual needs of the patient. Altering depth of submergence, speed of exercises performed, and the surface area of the body can affect the resistance profile of the water. For example, when stationary there is less resistance from the water on the body. However, during high-speed movements, the resistance from the water will increase. Therefore, high speed resistance training can be performed in water allowing for strength to be built with low impact on the joints. As a result, aquatic therapy can be used as an alternative to land-based strength exercise. \[41\] Water as a Compressor\[edit \\| edit source\] When a patient is submerged in water, they are subjected to hydrostatic pressure. This pressure has resultant effects on the body. For example, increased blood flow and circulation. This allows for greater oxygen delivery to the muscles and relaxation. Hydrostatic pressure can also compress the chest wall which alters pulmonary function and respiratory dynamics. As a result, work of breathing is increased by around 60% compared to that on land. This can actually strengthen respiratory muscles and improve the aerobic fitness of individuals. \[41\] Temperature\[edit \\| edit source\] Hydrotherapy pools are usually heated to between 28-32 degrees Celsius. When submerged, this warm pool temperature can increase blood flow and range of motion. It can also produce greater muscle elasticity which can be beneficial for patients experiencing tightness of the muscles, stiffness or spasticity.\[41\] Indications, Contraindications and Precautions to Aquatic Therapy\[edit \\| edit source\] Indications\[edit \\| edit source\] Management of muscle tone problems Decreased range of movement Decreased muscle strength Reduced balance Joint instability Pain Gait re-education Decreased sensation Neurological patients Patients who are willing to self-manage through a water-based exercise programme which they can continue with in pools available in leisure centres Patients who would benefit from aquatic physiotherapy in the short-term to then progress to land-based exercise when ready \[42\] This would include conditions such as: Fibromyalgia Hemiplegia Cerebral palsy Ankylosing spondylitis Juvenile idiopathic arthritis Parkinson’s Disease Obesity CLBP Multiple sclerosis Traumatic brain injuries Stroke Rheumatoid arthritis Contraindications\[edit \\| edit source\] Absolute Contraindications\[edit \\| edit source\] Patients with the following are not suitable to receive aquatic physiotherapy: Acute systemic illness/pyrexia Acute vomiting or diarrhoea Medical instability following an acute episode e.g., CVA, DVT Chlorine or bromine allergy Resting angina Shortness of breath at rest Uncontrolled cardiac failure Open infected wounds \[43\]\[44\] Relative Contraindications\[edit \\| edit source\] Known aneurysm Poorly controlled epilepsy Open wounds Thyroid deficiency Neutropenia Weight in excess of evacuation equipment limit Oxygen dependency Unstable diabetes – blood sugar may drop \[43\] \[44\] Precautions\[edit \\| edit source\] Incontinence of urine/faeces Epilepsy Hypotension Renal failure Poor skin integrity Risk of aspiration Prone to blackouts Sickle cell anaemia Tracheostomy Fear of water Pregnancy is water temperature exceeds 35°C Low calorie intake Equipment Used in Aquatic Therapy\[edit \\| edit source\] Resistance Aids\[edit \\| edit source\] Flippers/fins Aquatic Dumbbells Wrist and Ankle Weights Submersible Steps Equipment used in aquatic therapy - kickboards Floatation Aids\[edit \\| edit source\] Pool Noodles Aqua round body support Floatation Belts Arm Bands Kick boards Aqua Plinth Sensafloat Underwater Treadmill Cardiovascular Equipment\[edit \\| edit source\] Underwater Treadmill Underwater Stationary bike \[45\]\[46\]\[47\] Benefits of Aquatic physiotherapy\[edit \\| edit source\] Improved flexibility Improved balance Improved physical function Increased muscle strength and endurance Enhanced aerobic capacity Relaxation Increased mobility Decreased pain levels Improved Quality of Life \[48\]\[49\]\[50\]\[51\]\[52\]\[53\] Assessment and Diagnosis\[edit \\| edit source\] During the initial assessment, as recommended in the international back pain guidelines, it is important to examine the patient to diagnostically triage their presenting condition. \[54\] This includes screening patients with any new onset of back pain for red flag diagnosis (i.e. neurologic compromise, inflammatory disease, infection, trauma/ fractures, and cancer which may require emergency attention). \[55\] Additionally, it is important to identify other pathology or non-specific causes of back pain. NICE guidelines recommends considering using risk stratification such as the STarT Back risk assessment at first point contact for any new episodes of LBP (with or without sciatica) for shared decision-making. \[55\] Subjective History\[edit \\| edit source\] Undertaking a subjective history allows to build a rapport with your patient, gain a further insight into their LBP such as onset, duration, location, character, severity and aggravating and relieving factors in addition to identifying serious pathologies. Physical Assessment\[edit \\| edit source\] A physical assessment will follow the subjective history to clinically reason and confirm hypothesis. A physical assessment for the lower back will include the following: Observation – posture, abnormal deformity, and curvature Palpation – along spinous process and transverse process, musculature, sacroiliac joint Gait – through stance and swing phase Range of Motion – Passive and Active of lumbar, thoracic spine, and hip Muscle strength – Lumbar spine and Hip Neurological testing – Reflexes, Motor and sensory testing, straight leg raise, femoral nerve test Testing SIJ and Hip – thigh thrust test, pelvic compression, FABER’s Motor control testing – Waiter’s Bow, Pelvic tilts Imagining is not routinely offered in non-specialist setting for people with low back pain – NICE \[54\]\[55\] Patient-reported outcome measures\[edit \\| edit source\] Using patient-reported outcomes provides a patient's perceptive of their disease and treatment which we may not be able to gain through the subjective and objective assessment. It allows patients to track their progress, measure quality of care and management and provides motivation and adherence to treatment. \[56\] \[57\]\[58\] In a 2016 Delphi survey \[59\] which included an international multidisciplinary group of researchers, clinicians and patients updated the set outcome domains for LBP. These domains are mentioned below with the associated outcome measures with the best psychometric properties. Choosing the domain and outcome measure during clinical assessment will depend on various different factors such as the patient's level of function, disability and goals. It is recommended to use one of these measures due to reasons mentioned above considering the practitioners personal preference, practical aspects e.g. costs and availability \[58\] Physical function – Oswestry Disability Index or Roland Morris Disability Questionnaire Pain intensity – Numerical Rating Scale or Visual Analogue Scale Health-related quality of life – Short Form Health Survey 12 or EuroQol-5D-3L Work – Work Ability or Work productivity questionnaire Psychological functioning – Hospital Anxiety and Disability Scale Pain interference – Pain Interference subscale of the Brief Pain Inventory Psychosocial Effects of Chronic Low Back Pain\[edit \\| edit source\] Background\[edit \\| edit source\] Known predictors of chronicity and disability in patients with LBP include; depression, distress, and somatisation. \[60\] Psychological factors that are associated with all chronic pain include depression and anxiety, fear avoidance, low self-efficacy, and post-traumatic stress disorder \[60\] \[61\] \[62\]. Finally, social factors include abstaining from work, detaching and isolating from others and compensatory mechanisms. \[60\] The Biopsychosocial Model of Chronic Pain\[edit \\| edit source\] Numerous psychosocial factors are associated with CLBP, therefore a biopsychosocial perspective is important to provide optimal care. \[63\] The biopsychosocial model of back pain is based on a holistic view which recognises the reciprocal influences of the biological, psychological, and social variables that influence LBP. Due to the variable human experiences of back pain, this is vital to understand. \[64\] Demonstrated in the image below. Bio: physiological pathology Psycho: behaviours, thoughts and emotions such as psychological distress, fear/avoidance beliefs, current coping methods and attribution Social: socio-economical, socio-environmental, and cultural factors such as work and family BPS Model of Chronic Low Back Pain Duenas \[65\] explains that chronic pain causes significant consequences for not only patients but their professional and social environment and therefore both social and psychological domains are important to understand. \[65\] Psychosocial Factors Influence Ones' Life\[edit \\| edit source\] Psychosocial factors cause a continuous detrimental cycle whereby they not only affect the back pain but also one’s life. For example, depressive symptoms may worsen back pain and therefore increase the disability associated with back pain. \[63\] Back pain patients are more likely to experience: Anxiety disorders Major depressive disorders The coexistence of these conditions and associated back pain may lead to decreased quality of life and a greater chronicity. Despite this, mechanisms of the associations that underly CLBP are still not fully understood. \[66\] Avoidance Behaviour - Anxiety\[edit \\| edit source\] There are two pathways in which people may take when experiencing LBP. The first is that they continue their daily life by moving normally, which intern helps the recovery process. However, the other pathway evolves when a patient begins to avoid movements, potentially due to pain-related fear, anxiety, or to seek safety. This can lead to cycles of greater disability and increasing pain, and thus the maintenance of chronic pain. This is described in the Fear Avoidance and Beliefs Model (FAMB). \[67\] Fear Avoidance and Beliefs Model Low Back Pain and Depression\[edit \\| edit source\] A study by Robertson \[68\] with 1013 first year Canadian university students looked at the association between LBP and depression and somatisation in adults. Participants completed the modified Zung Depression Index, the modified somatic perception questionnaire and a survey about low back pain and intensity. Results revealed over 50% of subjects reported LBP across grades, and both depression and somatisation was positively associated with LBP, consistent with other studies and reinforcing the understanding of the detrimental association. \[68\] Summary\[edit \\| edit source\] The deleterious cycle of psychosocial factors and CLBP impact many people worldwide. Psychosocial factors not only impact back pain but also play a role in how the pain impacts one's life. Therefore, it is important to be aware of the psychosocial element that plays such a huge role in the assessment, management and treatment of LBP. For example, use psychosocial outcome measures with patient to measure their current presenting condition and improvements (HADS), as discussed previously. The Effectiveness of Aquatic Therapy for Chronic Low Back Pain\[edit \\| edit source\] The standardised approach for the management of CLBP is multi-modal. The NICE guidelines recommend: \[55\] Self-management Advice and information from health care professionals to allow patients to self-manage their pain Activity modification Information about the nature of their back pain Exercise Type of exercise should take into account the patients' specific needs, preferences and capabilities Group exercise programmes are recommended Manual Therapy Spinal Manipulation, mobilisation and soft tissue techniques in addition to exercise Psychological therapy CBT approach for managing LBP in addition to exercise Consider a combined physical and psychological programme Promote and facilitate return to work and normal activities Pharmacological approach Oral NSAIDs Lowest effective dose for the shortest amount of time Weak opioids if NSAIDs are contraindicated Within these NICE guidelines the importance is placed upon exercise and making sure the type of exercise takes into account the specific needs and preferences of the individual patient. Often, patients are prescribed land-based exercises focusing on strengthening, stretching and motor control. However, when walking or moving on land, our spine gets compressively loaded due to gravity and body positions which can increase intradiscal pressure. \[69\]\[70\] This is important to note because increased of loading of the facet joints, and other spinal structures has been suggested as a potential cause LBP. \[71\] Pressure on Lumbar Discs based on body position This is why it is important to consider alternative treatment options to land-based exercise which decrease this spinal loading. For example, aquatic therapy can be indicated as a management option for CLBP because the unique properties of water allow for exercise in a medium which reduces pressure on joints. The main benefits of aquatic therapy for CLBP are: Decreased Pain Increased Function Decreased Disability Aquatic therapy for improving pain\[edit \\| edit source\] As previously stated, aquatic therapy can have benefits for CLBP by decreasing patients self-reported pain levels. In research, this is often measured using visual analogue scales (VAS). A randomised control trial by Baena-Beato et al.\[72\] researched the effect aquatic therapy had on sedentary patients with CLBP. The 49 participants were split into aquatic therapy and waiting list groups who received advice and education (control). Results found that after 2 months of the aquatic therapy programme, participants experienced significantly improved LBP (VAS) at rest, and lumbar flexion and extension compared to the control group. Body composition was also measured, with weight and BMI decreasing for the aquatic therapy group compared to the control. However, this was a small sample size and only evaluated sedentary patients which could impact the generalisation of these results to the wider population. Aquatic therapy decreasing pain for patients with CLBP has been supported by a systematic review and meta-analysis Shi et al.\[73\] This review included 8 trials with a total of 331 participants, looking at the effectiveness of aquatic therapy for CLBP patients. Sessions ranged from 2-5x a week and from 30-80-minute sessions over a period of 4-15 weeks. Comparison groups either received land-based therapy, standard general practice, or no exercise. Results showed that patients who took part in aquatic therapy experienced a statistically significant reduction in self-reported pain (VAS) compared to the control groups. However, these changes were not always reported as clinically significant. Aquatic therapy for improving disability and function\[edit \\| edit source\] CLBP is one the leading cause of disability worldwide.\[2\] As a result, physical function is compromised, and patients often struggle to complete their activities of daily life and work-related activities. Aquatic therapy aims to improve these two symptoms of CLBP. A randomised control trial by Dundar et al.\[74\] assessed 65 patients with CLBP. They were randomly assigned aquatic exercise or land-based exercise. After 4 weeks, both groups improved in all outcome measures compared to baseline. However, the aquatic exercise group showed a significantly better improvement in the Oswestry Low back pain disability questionnaire and the physical function section of the SF36. This was further supported by a systematic review. \[75\]A total of 7 trials were included in the review, and results showed that compared to no intervention, aquatic therapy resulted in a significant improvement in function (Oswestry Disability index). However, the improvements were no better than other interventions. Aquatic Therapy vs Other Therapies\[edit \\| edit source\] Land-based therapy is recommended for patients with LBP as an intervention to increase range of motion, flexibility, and strength. As mentioned above, aquatic therapy has a wide range of benefits on patients with LBP. Here are two studies comparing aquatic and land-based therapy for patients with LBP: A study by Hend et al. \[76\] conducted a randomised control trial comparing aquatic therapy (n=30) to land-based therapy (n=30) on pain level, functional ability, and lumbar range of motion in CLBP patients. In a population of 60 participants, on multivariate analysis, a statistically significant multivariate effects were found for the main effects of groups for time and interaction between groups and time. Additionally, on univariate analysis, a statistically significant difference (p\<0.05) between the groups were observed, favouring the aquatic group for VAS, ODI, flexion, extension, and side flexion outcome after 4 weeks. Land-based exercises did show statistical improvements in pain intensity, ODI and lumbar flexion however no difference was observed in extension and right and left side flexion with aquatic therapy group showing significant results in all outcome measures. However, this study had no control group and did not evaluate the long-term effects of using water-based therapy therefore could have been impacted by bias reducing its validity and reliability. Another randomised control trail by Peng et al. \[77\] compared aquatic therapy to physical activity modalities (TENS). In a population of 113 participants, they were split into aquatic group (56) and physical therapy modalities group (57). After treatment for 12 weeks, which comprised to 60-minute sessions twice per week for a total of 24 sessions, a statistically significant clinically meaningful improvement was observed in disability scores (Roland Morris) in the aquatic group compared to physical modalities after 3, 6 and 12 months (p\<0.001). In addition, there was significant improvement in pain rating at 3,6 and 12 months in the aquatic group compared to physical modalities (p\<0.001). However, this study had no control group, increasing risk of bias and were unable to determine if benefits were from an active warm-up thus reducing validity. On the other hand, a study by Nemcic et al. \[78\] demonstrated no significant difference between an aquatic therapy group and land-based group after a 3 week programme in lumbar mobility and physical disability demonstrating either modality is modality is beneficial in managing LBP. Psychosocial Effects of Aquatic Therapy on Chronic Low Back Pain\[edit \\| edit source\] Introduction\[edit \\| edit source\] There are numerous psychosocial benefits from engaging in aquatic physiotherapy and recent research explains that all aquatic exercise is vital in promoting and managing mental health. Firstly, partaking in physical exercise can have many positive effects on quality of life due to the facilitation and promotion of social interaction. \[79\] \[80\] \[81\] On the other hand, psychosocial stressors and a sedentary lifestyle has been shown to reduce cellular functioning. Thus, promoting physical exercise is vital when treating and preventing depression \[82\] and other mental health disorders. Psychosocial benefits\[edit \\| edit source\] Stress relief Relaxation of muscles Water is associated with fun and relaxation Promotes body awareness Increases self-efficacy and confidence Group Hydrotherapy Session The warm water and physical properties of water (buoyancy and hydrostatic pressure) can provide stress relief allowing the muscles to relax, leading to tension relief and a reduction in muscle spasms, \[83\] promoting a less anxious state. Women partaking in aquatic physiotherapy report feeling comfortable and relaxed in the warm water. \[84\] Additionally, aquatic therapy can provide a sense of control and understanding of your own body due to the hydrostatic pressure promoting sensory receptors, allowing patients to take back control of their own movements, increasing self-efficacy and confidence. \[85\] Aquatic physiotherapy, depression and quality of life\[edit \\| edit source\] Silva \[81\] completed a study with 30 elderly participants to determine the effects of aquatic exercise on mental health. The participants were allocated into two groups (depression group and non-depression group) in which they completed an aquatic exercise programme for 12 weeks. They discovered that, in depressed elderly individuals, aquatic physiotherapy reduces depression and anxiety, improves activities of daily living, and reduces oxidative stress. A clinical trial of sedentary adults with CLBP by Beato, \[86\] examined the prognostic factors and disability change after a two-months intensive aquatic therapy programme compared to the control group. They discovered among others changes that quality of life improved. Suggesting an improvement in the patients psychosocially after an aquatic physiotherapy programme. Swim England Supports Aquatic Physiotherapy\[edit \\| edit source\] Swim England’s 2019 Value of Swimming report and the 2021 Decade of Decline report were both created to encourage and improve the awareness of swimming and aquatic therapy. Their overall aim is to prevent the closures of hydrotherapy pools. They report that this is because of the positive impact aquatic physiotherapy can have on one's physical and mental well-being. \[87\] The video below was made by Swim England, and shares Dominic's story, who has cerebral palsy and has been in a wheelchair most of his life. Dominic says "I can walk by myself, swim by myself, just do everything in the water by myself, it really promotes my independence.” \[87\] “I think the main impact that aquatic physiotherapy has had on Dom is that it has both physical, physiological and psychosocial benefits." - Jacqueline Pattman. \[87\] Aquatic Physiotherapy Prescription\[edit \\| edit source\] As previous studies have shown, aquatic physiotherapy can be proven useful for reducing symptoms of CLBP. However, the question remains as to how frequent this intervention needs to take place for it to be effective in the short and long-term. Frequency Per Week\[edit \\| edit source\] There are a couple studies which look at the effect of different frequencies for this intervention. For example, Baena-Baeato et al.\[88\] compared the effect of completing aquatic therapy either 2x or 3x a week for CLBP patients over an 8-week period. This study included 54 participants who had CLBP for more than 12 weeks. They were split into a control group (education/advice only), aquatic therapy 2x a week and then aquatic therapy 3x a week. Outcome measures of pain, disability, quality of life, body composition and health related fitness were used to determine the effects of the different frequencies. Results showed that both groups experienced significant improvements in back pain and disability compared to the control group. However, the 3x a week group showed significantly greater benefits with pain into flexion and disability levels compared to the 2x a week group. Both groups experienced significantly improved quality of life and health related parameters. There were no significant changes between the treatment groups and control in regard to body composition. Another study \[89\] investigated the optimal frequency of aquatic therapy for individuals with chronic musculoskeletal pain. This randomised control trial included 114 people with chronic musculoskeletal pain and had them participate in aquatic therapy either 2x or 3x a week for a year. Patients included experienced 1 of 3 musculoskeletal disorders: chronic lower back pain, chronic neck pain or osteoarthritis. Outcome measures included quality of life, disability index and WOMAC for OA patients. Measurements were taken at baseline, 8 weeks, 6 months and a year after the programme started. Results showed that there were no statistical differences between the two groups except the neck disability index at 8 weeks. There were improvements for all groups and all variables from baseline to a year. Length of Session and Content of Session\[edit \\| edit source\] Both studies \[88\] \[89\]included aquatic therapy sessions which were on average 60 minutes long. This is consistent with other studies which look generally at the effectiveness of aquatic therapy on CLBP. For example, in a systematic review, \[53\] 13 studies were reviewed, and the majority used interventions of aquatic therapy ranging from 45-60 minutes. Aquatic therapy sessions included warmups, muscle strength exercises, aerobic exercises and cool downs working on flexibility. This systematic review concluded that aquatic therapy improved pain, disability, and quality of life. What the Evidence Suggests\[edit \\| edit source\] As a result of these studies, it can be concluded that the optimal aquatic therapy prescription for CLBP patients should be 2x a week for 60-minute sessions. These sessions should include a mixture of aerobic and resistance exercises as well as a warmup and cool down. This knowledge has implications for rehabilitation, as it shows that 2x a week is often comparable to 3x a week of aquatic therapy for outcomes of CLBP. This can save resources and cost for patients and service providers without compromising the effects of the treatment. Conclusion\[edit \\| edit source\] CLBP is a highly common health issue within the population. It is a complex condition which has both biological and psychosocial components which need to be considered. As a result is important to investigate different treatment interventions on all of these components, measured by relevant outcome measures. Aquatic therapy has been proven to have extra benefits from land based training due to the unique properties of water, hence the decision to investigate the effect of this treatment on chronic low back pain. Literature has demonstrated multiple benefits of aquatic therapy in CLBP. These benefits include a decrease in pain levels and improvements in disability and function. Additionally, aquatic therapy has been shown to have psychological benefits which include improvements in self efficacy, confidence and anxiety/depression for patients with CLBP. However, it is important to consider the limitations present within the studies when considering treatment options as currently there is not sufficient comprehensive research to suggest aquatic therapy is superior over land based exercise. Despite this, it is noteworthy that aquatic therapy can provide similar benefits to land based exercise with the addition of relaxation from the warm water. The choice of intervention for chronic low back pain should be based upon individual assessment and preference of therapist and/or patient.](https://www.physio-pedia.com/Aquatic_Therapy_in_the_Management_of_Chronic_Low_Back_Pain?utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal) ## References\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=25 "Edit section: References") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=25 "Edit section: References")\] 1. ↑ [Jump up to: 1\.0](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-0) [1\.1](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-1) [1\.2](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-2) [1\.3](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-3) [1\.4](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-4) De Campos TF. 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A systematic review and meta-analysis.](https://pubmed.ncbi.nlm.nih.gov/35151908/) J Sport Health Sci. 2022 Jul;11(4):450-465. 26. ↑ [Jump up to: 26\.0](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:18_26-0) [26\.1](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:18_26-1) [26\.2](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:18_26-2) Lawford BJ, Walters J, Ferrar K. [Does walking improve disability status, function, or quality of life in adults with chronic low back pain? A systematic review.](https://pubmed.ncbi.nlm.nih.gov/26088673/) Clin Rehabil. 2016 Jun;30(6):523-36. 27. ↑ [Jump up to: 27\.0](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:19_27-0) [27\.1](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:19_27-1) [27\.2](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:19_27-2) Lee JS, Kang SJ. 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[Is physiotherapy integrated virtual walking effective on pain, function, and kinesiophobia in patients with non-specific low-back pain? Randomised controlled trial.](https://pubmed.ncbi.nlm.nih.gov/27981455/) Eur Spine J. 2017 Feb;26(2):538-45. 30. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-30 "Jump up") Norris MK, Fox FS, Lee C, Wang E, Green K, Yan H, Dieli-Conwright CM. [Narrowing the gap for minority cancer survivors: exercise oncology in the past, present, and future.](https://meridian.allenpress.com/jcep/article/9/4/155/451460/Narrowing-the-Gap-for-Minority-Cancer-Survivors) Journal of Clinical Exercise Physiology. 2020 Dec;9(4):155-70. 31. ↑ [Jump up to: 31\.0](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:22_31-0) [31\.1](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:22_31-1) Nicolson PJ, Bennell KL, Dobson FL, Van Ginckel A, Holden MA, Hinman RS. [Interventions to increase adherence to therapeutic exercise in older adults with low back pain and/or hip/knee osteoarthritis: a systematic review and meta-analysis.](https://pubmed.ncbi.nlm.nih.gov/28087567/) Br J Sports Med. 2017 May 1;51(10):791-9. 32. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-32 "Jump up") Pickle NT, Grabowski AM, Auyang AG, Silverman AK. [The functional roles of muscles during sloped walking.](https://pubmed.ncbi.nlm.nih.gov/27553849/) J Biomech. 2016 Oct 3;49(14):3244-51. 33. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-33 "Jump up") Jung J, Yu J, Kang H. [Differences in trunk muscle activities and ratios between unstable supine and prone bridging exercises in individuals with low back pain](https://www.jstage.jst.go.jp/article/jpts/24/9/24_889/_pdf). Journal of Physical Therapy Science. 2012;24(9):889-92. 34. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-34 "Jump up") Chiarotto A, Maxwell LJ, Ostelo RW, Boers M, Tugwell P, Terwee CB. [Measurement properties of visual analogue scale, numeric rating scale, and pain severity subscale of the brief pain inventory in patients with low back pain: a systematic review.](https://pubmed.ncbi.nlm.nih.gov/30099210/) J Pain. 2019 Mar 1;20(3):245-63. 35. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-35 "Jump up") WeCapable.com. Visual Analogue Scale for pain (VAS): Scoring pain on 100mm line. Disability information. 2022. Available from: <https://wecapable.com/vas-pain-scale-100mm-line/> \[accessed 27/5/2023\] 36. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-36 "Jump up") Olaogun MO, Adedoyin RA, Ikem IC, Anifaloba OR. [Reliability of rating low back pain with a visual analog scale and a semantic differential scale.](https://www.tandfonline.com/doi/abs/10.1080/09593980490453048) Physiotherapy Theory and Practice. 2004 Jan 1;20(2):135-42. 37. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-37 "Jump up") Shafshak TS, Elnemr R. [The visual analog scale versus numerical rating scale in measuring pain severity and predicting disability in low back pain.](https://pubmed.ncbi.nlm.nih.gov/31985722/) J Clin Rheumatol. 2021 Oct 1;27(7):282-5. 38. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-38 "Jump up") Chiarotto A, Maxwell LJ, Terwee CB, Wells GA, Tugwell P, Ostelo RW. [Roland-Morris Disability Questionnaire and Oswestry Disability Index: which has better measurement properties for measuring physical functioning in nonspecific low back pain? Systematic review and meta-analysis](https://pubmed.ncbi.nlm.nih.gov/27081203/). Phys Ther. 2016 Oct 1;96(10):1620-37. 39. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-39 "Jump up") PrimePhysio. Roland-Morris Disability Questionnaire. Orthopaedic manual therapy certificate. Available from: <https://www.primephysio.com/forum/_omtc/roland-morris-disability-questionnaire-rmdq> \[accessed 27/5/ 2023\] 40. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-40 "Jump up") Burbridge C, Randall J, Abraham L, Bush E. [Measuring the impact of chronic low back pain on everyday functioning: content validity of the Roland Morris disability questionnaire.](https://pubmed.ncbi.nlm.nih.gov/32857224/) J Patient Rep Outcomes. 2020 Dec;4(1):1-5. 41. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-41 "Jump up") Fairbank JC, Pynsent PB. [The Oswestry Disability Index.](https://pubmed.ncbi.nlm.nih.gov/11074683/) Spine (Phila Pa 1976). 2000 Nov 15;25(22):2940-52 42. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-42 "Jump up") Haegg O. [Oswestry Disability Index.](https://link.springer.com/referenceworkentry/10.1007/978-3-642-28753-4_3021#howtocite) Encyclopedia of Pain. 2013 Edition. Available from: <https://link.springer.com/referenceworkentry/10.1007/978-3-642-28753-4_3021#howtocite> \[accessed 27/5/2023\] 43. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-43 "Jump up") Jalil N, Sulaiman Z, Awang M, Omar M. [Retrospective Review of Outcomes of a Multimodal Chronic Pain Service in a Major Teaching Hospital: A Preliminary Experience in Universiti Sains Malaysia.](https://pubmed.ncbi.nlm.nih.gov/22135513/) Malays J Med Sci. 2009; 16(4): 55-65. 44. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-44 "Jump up") Lee CP, Fu TS, Liu CY, Hung CI. [Psychometric evaluation of the Oswestry Disability Index in patients with chronic low back pain: factor and Mokken analyses.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5627480/) Health Qual Life Outcomes. 2017 Dec;15(1):1-7. 45. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-45 "Jump up") Fairbank J, Pynsent P. [The Oswestry Disability Index](https://pubmed.ncbi.nlm.nih.gov/11074683/). Spine 2000; 25(22):2940-53. 46. [↑](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-46 "Jump up") Forde C. [Scoring the International Physical activity questionnaire (IPAQ).](https://ugc.futurelearn.com/uploads/files/bc/c5/bcc53b14-ec1e-4d90-88e3-1568682f32ae/IPAQ_PDF.pdf) Exercise prescription for the prevention and treatment of disease, University of Dublin 2018; 3. Available from: <https://ugc.futurelearn.com/uploads/files/bc/c5/bcc53b14-ec1e-4d90-88e3-1568682f32ae/IPAQ_PDF.pdf> \[accessed 27/5/2023\] 47. ↑ [Jump up to: 47\.0](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:2_47-0) [47\.1](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:2_47-1) Craig C, Marshall A, Sjöström M, Bauman A, Booth M, Ainsworth B, Pratt M, Ekelund U, Yngve A, Sallis J, Oja P. [International physical activity questionnaire: 12-country reliability and validity.](https://pubmed.ncbi.nlm.nih.gov/12900694/) Med Sci Sports Exerc. 2003 Aug 1;35(8):1381-95. 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Readable Markdown	## Introduction\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=1 "Edit section: Introduction") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=1 "Edit section: Introduction")\] [Low back pain](https://www.physio-pedia.com/Low_Back_Pain) (LBP) that is not associated with serious or potentially serious causes has been described in the literature as '[non-specific](https://www.physio-pedia.com/Non_Specific_Low_Back_Pain)', 'mechanical', 'musculoskeletal', or 'simple' LBP.[\[1\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1) [Non-specific](https://www.physio-pedia.com/Non_Specific_Low_Back_Pain) LBP is defined as LBP not attributable to a recognisable specific pathology (eg, infection, tumor, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome).[\[2\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-2) [![](https://www.physio-pedia.com/images/thumb/3/3e/Lower_back_pain.png/200px-Lower_back_pain.png)](https://www.physio-pedia.com/File:Lower_back_pain.png) LBP between the rib cage and gluteal folds LBP can be further split into three categories; acute, sub-acute, and [chronic](https://www.physio-pedia.com/Chronic_Low_Back_Pain).[\[3\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-3) 1. Acute is anything that persists for less than 6 weeks. 2. Sub-acute is anything persisting between 6-12 weeks. 3. [Chronic](https://www.physio-pedia.com/Chronic_Low_Back_Pain) is anything persisting for 12 weeks or more. LBP is commonly described to be between the anatomical regions of the ribs and gluteal folds.[\[4\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:1-4) ## Anatomy\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=2 "Edit section: Anatomy") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=2 "Edit section: Anatomy")\] The [lumbar spine](https://www.physio-pedia.com/Lumbar_Anatomy "Lumbar Anatomy") comprises the lower end of the spinal column between the last [thoracic](https://www.physio-pedia.com/Thoracic_Anatomy "Thoracic Anatomy") vertebra (T12) and the first [sacral vertebra](https://www.physio-pedia.com/Sacrum "Sacrum") (S1). There is a total of five lumbar vertebrae (L1-L5) that are much larger compared to other regions within the vertebral column. These large [facets](https://www.physio-pedia.com/Facet_Joints "Facet Joints") help support the upper body, as they absorb axial forces (against gravity) delivered from the head, neck, and trunk, and provide protection for the spinal cord from the canal that is formed. The lumbar spine allows for diverse types of trunk motion, including flexion, extension, rotation, and side bending, thus providing further reasons as to why the facets are much larger. Each lumbar segment consists of multiple components; vertebral body, transverse process, super articular process, super articular facet, intervertebral disc, vertebral forearm, the pedicle of the vertebral arch, lamina of the vertebral arch, and a spinous process.[\[5\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-5) Due to the complex structure of spinal components, discs, intervertebral joints, muscles, and nerves, LBP can present with the same symptoms from different causes. ## Epidemiology\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=3 "Edit section: Epidemiology") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=3 "Edit section: Epidemiology")\] LBP causes more disability than any other condition, affecting 1 in 10 people and becoming more common with increasing age, [\[1\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1)with rates of 1%–6% in children aged 7–10 years, 18% in adolescents, and a peak prevalence ranging from 28% to 42% in people between 40 years and 69 years.[\[6\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:3-6) The prevalence of LBP is thought to be increasing due to an increasing and aging population [\[7\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-7) with estimates of life time prevalence being as high as 84% in the adult population. [\[8\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-8) [![](https://www.physio-pedia.com/images/thumb/6/6f/Picture_.png/300px-Picture_.png)](https://www.physio-pedia.com/File:Picture_.png) One study that was carried out in 195 countries assessing the incidence, prevalence, and years lived with disability for 354 medical conditions found LBP to be the leading cause of worldwide productivity loss as measured in years, and the top cause of years lived with disability in 126 countries.[\[6\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:3-6) In the United Kingdom (UK), it is estimated that LBP is responsible for 37% of all [chronic pain](https://www.physio-pedia.com/Chronic_Pain_and_the_Brain "Chronic Pain and the Brain") in men and 44% in women and the total cost of LBP to the UK economy is reckoned to be over £12 billion per year. [\[1\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1) Risk factors for LBP are age, sex, height, weight, sedentary lifestyle, depression, anxiety, insomnia, and smoking.[\[10\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-10) Although muscle strain and imbalance, ligament sprain, and soft tissue damage account for almost all LBP, as it is [non-specific](https://www.physio-pedia.com/Non_Specific_Low_Back_Pain), it often has no identifiable underlying condition or origin. [\[11\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-11) Office workers are usually required to sit for long hours working on a computer while spending most of their time in a sitting position. Approximately 34%- 51% of office workers experienced LBP in the preceding 12 months. Occupational groups exposed to 'poor postures' while sitting for longer than half a day have a considerably increased risk of experiencing LBP. Subjects with LBP are likely to be in sustained postures and have large and infrequent spinal movements. Prolonged postural loading of the spine while sitting can reduce joint lubrication, fluid content of intervertebral discs, and increased stiffness. Additionally to this, prolonged muscle activation in static sitting may lead to localised muscle tension, muscle strains, muscle fatigue, and other soft-tissue damage, causing impairment of motor coordination and control as well as increased mechanical stress on ligaments and intervertebral discs.[\[12\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-12) Prevalence of [walking in the United Kingdom](https://www.gov.uk/government/statistics/walking-and-cycling-statistics-england-2020/walking-and-cycling-statistics-england-2020): - People made an average of 236 walking trips and walked an average of 220 miles. - People on average have walked less than in 2019, following a fall in short walks. - People walked 7% farther in 2020 compared to 2019. - 67% of adults in England reported walking at least once a week. - 92% of local authorities had at least 60% of their adult population walking at least once a week. The NHS provides a guide on ['walking for health'](https://www.nhs.uk/live-well/exercise/running-and-aerobic-exercises/walking-for-health/), to help motivate the population and help them meet the recommended minimum moderate activity guidelines of 150 minutes. ## Pedometer Driven Walking\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=4 "Edit section: Pedometer Driven Walking") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=4 "Edit section: Pedometer Driven Walking")\] [![](https://www.physio-pedia.com/images/f/f9/Pedometer._jp.jpg)](https://www.physio-pedia.com/File:Pedometer._jp.jpg) Example of a pedometer [Pedometers](https://www.prevention.com/fitness/a20450112/walking-tips-how-to-use-a-pedometer/) are devices that work by counting the steps someone takes to estimate the distance they have traveled. [\[13\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-13) Pedometers are usually worn at the hip (on the waistband of clothing) and in alignment with the patella although this may not be the case for all pedometers. There are also other ways of tracking steps - many people now have fitness trackers which are attached to the wrist and will also have the ability to count steps. Instructions will be included with pedometer devices, and as there are many [different types](https://www.prevention.com/fitness/a20450112/walking-tips-how-to-use-a-pedometer/) it is important to check these before usage to ensure that the pedometer is being used as accurately as possible. Some pedometers may also be more complex and do a little bit more than just counting steps such as showing calories burned, activity times, and memory logs. Whilst not a pedometer in the traditional sense, the [NHS](https://www.nhs.uk/better-health/get-active/) (National Health Service) also has an application which is free to download called 'Active 10' - this is designed to track walking and will indicate the total amount walked and how much of that was brisk walking. Within the app, there are also options to set goals, achieve milestones, and view progress over the weeks and months. So a pedometer is not the only option to keep a track of walking and daily activity - there are many more apps out there that will do the same thing\! Using an app as a pedometer or walking tracker does rely on the individual having a mobile phone and keeping it in their pocket to ensure it tracks all activity whereas a standard pedometer can be used by a wider number of people and may not be as complex. ### Do Pedometers Increase Physical Activity?\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=5 "Edit section: Do Pedometers Increase Physical Activity?") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=5 "Edit section: Do Pedometers Increase Physical Activity?")\] [The NICE (National Institute for Health and Care Excellence) guidelines](https://www.nice.org.uk/news/article/nice-publishes-updated-advice-on-treating-low-back-pain) on LBP and sciatica in over 16s - published in 2016 and last updated in 2020 - advises self-management and exercise as treatments. [\[1\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1)A pedometer would be an easy way of giving someone a tool to help self-manage their activity levels, as long as this was an appropriate choice of exercise for the individual - those with LBP should be encouraged to continue with their regular activities as well. [\[1\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:0-1) A three-arm cluster, randomised control trial (RCT) conducted in 2016 with an eventual number of participants at 956 recruited from primary care settings, found that a pedometer-based walking intervention (regardless of whether there was nurse support) increased the step count and physical activity of generally inactive 45-75 year old at a 12 month follow up. [\[14\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-14)A meta-analysis in 2009 of pedometer-based interventions for activity conducted in 2013 included 32 studies and found using pedometers to have a positive effect on physical activity and this was regardless of age or intervention length.[\[15\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:13-15) The studies had varying interventions from keeping a daily log of steps, completing 10,000 steps, individualized goals, or a combination of strategies.[\[15\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:13-15) ### Do Pedometers Affect LBP?\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=6 "Edit section: Do Pedometers Affect LBP?") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=6 "Edit section: Do Pedometers Affect LBP?")\] #### Acute Low Back Pain (ALBP)\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=7 "Edit section: Acute Low Back Pain (ALBP)") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=7 "Edit section: Acute Low Back Pain (ALBP)")\] There is arguably less research in relation to ALBP and the effects of using a pedometer. However, a study in 2015, focusing on those with ALBP of 48 hours or less looked at whether 'stay active' advice or 'adjusting activities to pain' had different effects. [\[16\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:14-16) Participants were aged between 18 and 65 and all were provided with a pedometer to track daily steps with the instruction of wearing it at all times during waking hours, they found the pedometer an easily used intervention which increased physical activity, particularly in those with the advice to 'stay active'.[\[16\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:14-16) This study shows that pedometers could have a useful place in treatment alongside other advice and management techniques for those with ALBP despite the study being over a short period of time, and the study size is relatively small. #### Chronic Low Back Pain (CLBP)\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=8 "Edit section: Chronic Low Back Pain (CLBP)") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=8 "Edit section: Chronic Low Back Pain (CLBP)")\] As previously mentioned, [CLBP](https://www.physio-pedia.com/Chronic_Low_Back_Pain "Chronic Low Back Pain") accounts for a significant amount of chronic pain in individuals of the UK, so interventions that aid in the treatment and management would be beneficial. A recent RCT published in 2021, looked at the effects of a pedometer-driven individualized walking plan compared to standardised care in increasing completion and adherence of physical activity in CLBP management.[\[17\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:15-17)Whilst no significant difference was noted in disability or pain, there was an indication that using an individualised, guided pedometer program aided in adherence and participation of physical activity - although relevant measures such as step count were not taken from the standardised care group, so it is unclear if there were any increases in physical activity amongst them.[\[17\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:15-17) A previous RCT from 2013, of an internet-based pedometer intervention, did find that in the short-term of 6 months back pain disability had decreased, but at 12 months there was no difference between the group with access to the internet support and the ones utilising the pedometer and standard management only.[\[18\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-18)Again, this shows, that whilst pedometer-driven walking can have positive effects in physical activity and adherence, there may need to be further research to explore how positive outcomes can be gained in the long term. It seems that pedometers can be a relatively cheap and accessibly form of intervention and management in individuals with LBP, and this can have greater positive impacts when included with support in one form or another.[\[16\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:14-16) ## Benefits of Walking on Low Back Pain\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=9 "Edit section: Benefits of Walking on Low Back Pain") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=9 "Edit section: Benefits of Walking on Low Back Pain")\] [![Walking dog.jpg](https://www.physio-pedia.com/images/thumb/b/b8/Walking_dog.jpg/300px-Walking_dog.jpg)](https://www.physio-pedia.com/File:Walking_dog.jpg) The lower back muscles play an important role in maintaining its stability and movement; two key aspects that are needed when walking. [\[19\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:6-19) These [muscles](https://www.physio-pedia.com/Muscle "Muscle") can become deconditioned in those with sedentary lifestyles, leading to weakness over time. This prolonged weakness can increase muscular fatigue, and injury, exaggerating the pain already being experienced. [\[19\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:6-19) Reduced physical activity can also cause these muscles and the joints of the [lumbar spine](https://www.physio-pedia.com/Lumbar_Anatomy "Lumbar Anatomy") to become stiff, which can increase the pressure on the lower back. [\[20\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:7-20) [Walking has many positive impacts on the lower back](https://www.verywellfit.com/walking-away-low-back-pain-3435479#toc-does-walking-really-prevent-low-back-pain), which can prevent or reduce these changes occurring in the following ways: 1. Increased blood flow: - Small blood vessels and capillaries in the lower back muscles can become constricted following decreased physical activity, [reducing the blood flow](https://www.spine-health.com/blog/2-reasons-why-walking-good-your-lower-back#vh_footnotes) to these muscles. - Walking allows for more movement in these muscles, allowing these capillaries and blood vessels to open up again. - This, in turn, increases the blood supply and nutrients to these muscles, improving muscular health and strength and aiding with the healing process. [\[20\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:7-20) 2. Stretch and contraction of muscles: - The movement in the lower back during walking increases the stretch and contraction of the lower back muscles and those in the legs, buttocks, and core, allowing for more flexibility and mobility in this area. - This flexibility [increases the overall range of motion](https://www.spine-health.com/blog/2-reasons-why-walking-good-your-lower-back#vh_footnotes) in the lower back, also improving the health and strength of the lower back muscles. [\[21\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-21) ## Treatment and Management\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=10 "Edit section: Treatment and Management") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=10 "Edit section: Treatment and Management")\] ### Effect Of Walking On LBP\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=11 "Edit section: Effect Of Walking On LBP") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=11 "Edit section: Effect Of Walking On LBP")\] Current evidence supports the use of walking as a treatment option for LBP. A cross-sectional study from 2017 evaluating the relationship between walking and LBP, consisting of 5,982 adults, found that walking was associated with a reduced risk of LBP. [\[22\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:9-22) The authors also found that the presence of LBP was proportionate to walking frequency, with those who walked more often having reduced LBP. These results are supported by those of a systematic review from 2019 evaluating the effects of walking on those with chronic LBP. [\[23\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:10-23) Walking was found to be as effective as other non-pharmacological interventions on pain and disability in short-term (\<3 months) and intermediate (3-12 months) follow-ups. These findings allowed for walking to be recommended for managing and treating LBP. [\[23\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:10-23) The effects of walking have been compared to the effects of exercise for LBP. A systematic review from 2019 comparing the two concluded that walking was as effective as exercise for improving pain, disability, quality of life, and fear-avoidance in those with chronic LBP. [\[24\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:11-24) Much like the studies by Kim et al. [\[22\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:9-22) and Sitthipornvorakul et al. [\[23\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:10-23), Vanti et al. [\[24\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:11-24) recommend the use of walking as a treatment and management option for LBP. Interestingly, a systematic review from 2022, found that people with LBP have altered gait patterns compared with healthy individuals. [\[25\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:12-25) Those with LBP were found to walk slower, have reduced stride lengths, greater lumbar paraspinal activation, and reduced thorax/pelvic coordination. [\[25\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:12-25) However, the authors were unable to report if these changes were adaptive or maladaptive. Overall, these results indicate that gait re-education may be needed for those with LBP to gain the most benefits from walking. A systematic review in 2015 included seven randomised controlled trials involving 869 participants adults with chronic LBP. It compared walking to other non-pharmacological management methods such as usual care, specific strength exercises, medical exercise therapy, or supervised exercise classes. It suggested that walking is the same effective as other management methods while having a lower cost. [\[26\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:18-26). It could be explained by its high accessibility, but does not require training, supervision, or specialised equipment. [\[26\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:18-26) Other research supported that walking is as effective as conventional physiotherapy treatment such as lumbar stabilisation and muscle strengthening exercise. [\[27\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:19-27)[\[28\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:20-28) A randomised control trial included 48 participants comparing the effect of lumbar stabilisation exercise and walking exercise on LBP. It suggested both interventions significantly reduced LBP, and both interventions show similar results.[\[28\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:20-28) Another randomised control trial compare strengthening exercise to a combined programme of strengthening exercise and walking exercise on chronic LBP. It suggested that both interventions were beneficial but combined exercise programme was more effective for reducing pain levels than the strength exercise. [\[27\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:19-27)Another randomised control trial also supported 44 participants comparing conventional physiotherapy to a combination of conventional physiotherapy with walking exercise. It suggested that a combination of conventional physiotherapy with walking exercise is more effective to reduces pain and kinesiophobia, and improved function in patients with subacute and chronic non-specific LBP. [\[29\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:21-29) ### How to Use Walking as a Treatment for LBP\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=12 "Edit section: How to Use Walking as a Treatment for LBP") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=12 "Edit section: How to Use Walking as a Treatment for LBP")\] #### 1\. Combine with conventional physiotherapy treatment\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=13 "Edit section: 1. Combine with conventional physiotherapy treatment") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=13 "Edit section: 1. Combine with conventional physiotherapy treatment")\] Walking is a low-cost intervention, and a combination of physiotherapy with walking is more effective than conventional physiotherapy alone. [\[26\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:18-26)[\[27\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:19-27)[\[29\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:21-29) Walking exercise could be educated by physiotherapists alongside their exercise prescription. Recommendations support the use of exercise for at least 15 to 30 minutes most days for those with LBP. [\[30\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-30) This can mean gradually building up walking distance and capacity to reduce the risk of injury and allow for the body to adapt to the changes. #### 2\. Goal setting\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=14 "Edit section: 2. Goal setting") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=14 "Edit section: 2. Goal setting")\] The use of a pedometer means that the patient is able to manage and keep track of their steps whilst walking. The patient might be advised to keep an "activity diary" which keeps track of a daily step count and the patient's step goal. This is achieved by calculating the patient's average step count in the first week of activity, and using this as a baseline when deciding a step goal for the second week. [\[31\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:22-31) The use of an activity diary can also help establish the patients' baseline in the first week, which is important in informing their individual goals for rehabilitation. [\[31\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:22-31) For example, use pedometer/tracking apps (like Active 10) to monitor and then set weekly targets (increase by a certain amount each week/two weeks for example). #### 3\. Postural Control\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=15 "Edit section: 3. Postural Control") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=15 "Edit section: 3. Postural Control")\] Having the [correct walking posture](https://www.verywellfit.com/how-to-walk-walking-posture-3432476) is important to allow for more comfortable walking, helping to reduce pain and discomfort. An optimal posture can be achieved using multiple strategies: 1. Stand up straight: - This can be achieved by making yourself as tall as possible, without leaning forwards or backward. - Ensuring your chin is kept up and your eyes facing forwards allows for reduced strain on your neck and back. - These together will allow for a better posture and improved balance. [\[32\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-32) 2. Keep shoulders back and relaxed: - Relaxing your shoulders helps relieve tension and allows for a more neutral spine when walking. 3. Engage core muscles and keep a neutral pelvis: - engaging your core and keeping a neutral pelvis prevents arching of the spine and tilting of the pelvis, allowing for a more neutral spine and better posture. [\[33\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-33) ## Outcome measures\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=16 "Edit section: Outcome measures") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=16 "Edit section: Outcome measures")\] There are a variety of outcome measures that might be used when advising walking as a management strategy for patients with LBP. These might look at: - Pain - Disability - Physical activity ### Pain\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=17 "Edit section: Pain") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=17 "Edit section: Pain")\] #### Visual Analogue Scale (VAS)\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=18 "Edit section: Visual Analogue Scale (VAS)") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=18 "Edit section: Visual Analogue Scale (VAS)")\] The VAS ([Visual Analogue Scale](https://www.physio-pedia.com/Visual_Analogue_Scale "Visual Analogue Scale")) is one of the most common outcome measures for LBP. [\[34\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-34) It is an example of a subjective PROM (Patient Reported Outcome Measure), where the patient records their pain on a 100mm line- from "no pain" at the beginning to the "worst pain imaginable". Some types of VAS also use faces to represent pain from "mild", "moderate" to "severe", as shown below. [![](https://www.physio-pedia.com/images/thumb/0/02/Visual_Analogue_Scale.jpg/300px-Visual_Analogue_Scale.jpg)](https://www.physio-pedia.com/File:Visual_Analogue_Scale.jpg) Previous studies have found that the VAS is a "reliable and valid" outcome measure for use in a LBP population. [\[36\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-36) It has also shown reliability in predicting disability due to LBP. [\[37\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-37) ### Disability\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=19 "Edit section: Disability") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=19 "Edit section: Disability")\] #### Roland-Morris Disability Questionnaire (RMDQ)\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=20 "Edit section: Roland-Morris Disability Questionnaire (RMDQ)") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=20 "Edit section: Roland-Morris Disability Questionnaire (RMDQ)")\] The [Roland-Morris Disability questionnaire (RMDQ)](https://www.physio-pedia.com/Roland%E2%80%90Morris_Disability_Questionnaire "Roland‐Morris Disability Questionnaire") is a commonly used PROM, designed to assess a patient's disability in relation to their LBP. It is a 24-item questionnaire that looks at physical functions that the patient feels have been affected, and a higher score represents a higher level of disability due to LBP. [\[38\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-38) [![](https://www.physio-pedia.com/images/thumb/0/0d/RMDQ_picture.webp/390px-RMDQ_picture.webp.png)](https://www.physio-pedia.com/File:RMDQ_picture.webp) An example of the RMDQ [\[39\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-39) A study from 2020 found that the RMDQ had good test-retest reliability and internal consistency reliability in capturing the "everyday functional impact of low back pain". [\[40\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-40) #### Oswestry Disability Index (ODI)\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=21 "Edit section: Oswestry Disability Index (ODI)") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=21 "Edit section: Oswestry Disability Index (ODI)")\] The [Oswestry Disability Index (ODI)](https://www.physio-pedia.com/Oswestry_Disability_Index "Oswestry Disability Index") is also commonly used to assess functional disability in patients with LBP. [\[41\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-41) It consists of 10 items which are detailed below, as well as the interpretation of the scores. [![](https://www.physio-pedia.com/images/thumb/4/41/ODI_QUESTIONS.jpg/390px-ODI_QUESTIONS.jpg)](https://www.physio-pedia.com/File:ODI_QUESTIONS.jpg) Oswestry Disability Index (ODI) [\[42\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-42) [![](https://www.physio-pedia.com/images/thumb/8/85/ODI_interpretation.png/300px-ODI_interpretation.png)](https://www.physio-pedia.com/File:ODI_interpretation.png) Interpretation of ODI scores [\[43\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-43) The ODI has been found to be a "valid and reliable scale suitable for measurement of disability for low back pain", and in particular showing high test-retest reliability. [\[44\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-44) A study looked at comparing the ODI and the RMDQ to each other. The study found that the ODI appeared to be better at detecting changes in patients with more severe lower back pain, whereas the RMDQ seemed to have an advantage when measuring patients who had more mild disability.[\[45\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-45) ### Physical activity\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=22 "Edit section: Physical activity") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=22 "Edit section: Physical activity")\] #### International Physical Activity Questionnaire (IPAQ)\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=23 "Edit section: International Physical Activity Questionnaire (IPAQ)") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=23 "Edit section: International Physical Activity Questionnaire (IPAQ)")\] The International Physical Activity Questionnaire (IPAQ) is formed of two different versions including the IPAQ short-form and the IPAQ long version. Both versions require the patient to recall their physical activity levels in the past 7 days. Based on these scores, they are placed in one of three categories: low activity levels, moderate activity levels, and high activity levels. [\[46\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-46) The [IPAQ short-form](https://evaluationframework.sportengland.org/media/1084/2015-ipaq-sf.pdf) consists of 4 categories where the patient reports how much they participated in the following activities in the past 7 days: - Moderate activity - Vigorous activity - Time spent walking - Time spent sitting The IPAQ short-form may be more beneficial for use in a clinical setting due to the shorter/more accessible nature of the questionnaire for patients. [\[47\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:2-47) The [IPAQ long version](https://www.physio-pedia.com/images/6/6e/International_Physical_Activity_Questionaire) assesses physical activity across 5 domains: 1. Job-related physical activity 2. Transportation physical activity 3. Housework, house maintenance, and caring for family 4. Recreation, sport, and leisure time 5. Time spent walking The IPAQ long version is typically used in research studies or may be used if a more detailed picture of a patient's physical activity levels is preferred. [\[47\]](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_note-:2-47) Overall, the [IPAQ](https://www.physio-pedia.com/images/6/6e/International_Physical_Activity_Questionaire) has been subject to extensive reliability and validity testing across 12 different countries (14 sites) from 2000 as an outcome measure for physical activity. ## Suggestions for Future Clinical Research\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=24 "Edit section: Suggestions for Future Clinical Research") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=24 "Edit section: Suggestions for Future Clinical Research")\] - Based on the current literature, walking has been shown to be an effective management strategy for patients with LBP. However, more high-quality RCT’s need to be carried out using a variety of outcome measures, including physical activity, to further investigate walking as an effective management strategy for LBP. - In order to strengthen the current evidence around this topic, further research could be carried out on how to ensure the long term effects of pedometer-based intervention. It would also be valuable to investigate whether added interventions might be necessary in aiding supportive positive outcomes long-term. - The current NICE guidelines for LBP and sciatica were published in 2016 and updated in 2020 for pharmacological interventions. However, the advice for “non-pharmacological interventions” last had an evidence review in 2016\. Therefore, it may be beneficial for a reassessment based on new evidence, in which guidelines around walking could be evaluated. ## References\[[edit](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&veaction=edit&section=25 "Edit section: References") \\| [edit source](https://www.physio-pedia.com/index.php?title=The_Effects_of_Walking_on_Low_Back_Pain&action=edit&section=25 "Edit section: References")\] 1. ↑ [Jump up to: 1\.0](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-0) [1\.1](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-1) [1\.2](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-2) [1\.3](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-3) [1\.4](https://www.physio-pedia.com/The_Effects_of_Walking_on_Low_Back_Pain#cite_ref-:0_1-4) De Campos TF. 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