Research Review Corner

In recent years, numerous high quality randomized trials and systematic
reviews have supported the use of exercise for treating chronic low
back pain (LBP) and neck pain.

Study Title: Exercise prescription for chronic back or neck pain: Who prescribes it? Who gets it? What is prescribed?
Author(s): Freburger JK, Carey TS, Holmes GM et al.
Publication Information: Arthritis & Rheumatism (Arthritis Care & Research) 2009; 61(2): 192-200.

Background Information:
In recent years, numerous high quality randomized trials and systematic reviews have supported the use of exercise for treating chronic low back pain (LBP) and neck pain. The goals of exercise include improving physical function and capacity, reducing symptoms of pain and stiffness, minimizing kinesiophobia (fear of movement), and reshaping patients’ views on their pain (consistent with a cognitive-behavioural approach).

 It is still unclear which type of exercise is most efficacious, and in what dose. However, a recent meta-analysis1 suggested that individually tailored, supervised exercise programs including stretching and strengthening are associated with better outcomes in those with chronic low back pain. A further interesting finding from a different review by the same author2 was that high-intensity exercise (defined as more than 20 hours total) combined with conservative treatments improved pain and function more than exercise alone, or low intensity exercise.

For chronic neck pain, the findings are similar, but not as conclusive. Current statements from the Bone and Joint Decade 2000-2010 Task Force on Neck Pain3 include:

• supervised and home exercise with advice is slightly more effective than advice only for chronic whiplash-associated neck pain
• exercise in addition to spinal manipulation is more effective than manipulation alone, TENS, or usual care for chronic neck pain
• both endurance and strengthening exercise are effective treatments for chronic mechanical neck pain
• multi-modal approaches that include exercise are likely better than single-treatment approaches

Despite this knowledge on the efficacy of exercise interventions, little is known about exercise prescription patterns in clinical practice. In particular:

• Who is prescribing it?
• What is being prescribed?
• Who is getting it?

Assessing these patterns would provide a good indication of the level of knowledge translation that is occurring, and highlight areas for improvement. This was the goal of this study.

Pertinent Results:

• In over 2,700 chronic neck or back pain patients, exercise of some sort was prescribed to 48 per cent of patients who had seen a medical doctor (MD), physiotherapist (PT), or chiropractor in the past year.
• Of this 48 per cent: 46 per cent received the prescription from a PT, 28.6 per cent from a physician, and 20.9 per cent from a chiropractor (4.6 per cent from “other”).
• For those who saw a chiropractor – 33.1 per cent were prescribed exercise.
• For those who saw a PT – 63.8 per cent were prescribed exercise.
• For those who saw a physician – 14.4 per cent were prescribed exercise.
• Overall, exercise prescription rates were not statistically different for back or neck pain.
• All professions seemed to provide instructions for appropriate exercise duration
• (average approximately 3.5 hours per week) – following this recommendation for six weeks would achieve the 20-hour mark mentioned above that is supported for chronic LBP
• The type of provider seen was the strongest predictor of exercise prescription – PTs were more likely to provide supervision, exercise in general, and stretching specifically.
• Patients who were female, more educated, on workers’ compensation, were employed in the last year, or had seen a PT or chiropractor were more likely to receive exercise prescription. (Variables that were almost significant included younger age, private insurance, no narcotic use, and higher physical therapy visits.)
• Those who were on Medicare (this was an American study), were in poorer general health, or reported greater disability were less likely to be prescribed exercise.
• A higher number of visits to a chiropractor raised the likelihood of exercise prescription.
• 86 per cent used more than one additional treatment – heat/cold and electrotherapy were most common for back pain, while heat/cold and manipulation were most common for neck pain

Conclusions and Practical Application:
Overall, this study suggests that exercise is being underutilized in clinical practice in the management of chronic neck and low back pain.

We should all take this study as a call to action – get your patients active! One of the only successful treatments for chronic neck and low back pain, exercise, was prescribed less than 50 per cent of the time in this large population-based study. Paradoxically, the type of practitioner was more influential than any patient-related factors in the prescription of exercise – the authors say “who you see is what you get”. Prudent clinicians should focus on the patient when prescribing exercise, regardless of his/her profession.

It may be expected that PTs are most likely to prescribe exercise, but it should be noted that roughly one-third of their patients, in this study, did not receive exercise. Less than half of patients consulting a physician received exercise, either from the doctor or from a subsequent referral to a PT or chiropractor.

Chiropractors were somewhere in the middle, prescribing exercise at a reasonable rate (roughly 33 per cent), and more frequently as patients saw them more. This may reflect a common practice pattern of attempting to reduce pain levels before
instituting exercise and rehabilitation.

In general, common barriers to exercise prescription could be provider knowledge and confidence. For those who do not have this background, adding a team member to your office who does can be a great asset, and based on existing literature, can improve care outcomes.

Study Methods:
Data was analyzed from a population-based survey of health care and treatment use in a population of chronic low back and neck pain patients4. The goals of the study were:

1. to assess the extent and details of exercise prescription by medical doctors, physical therapists, and chiropractors
2. to identify sociodemographic and work-related factors related to exercise prescription
3. to determine the level of supervision provided for exercise programs
4. to evaluate the extent to which other conservative treatments are used in conjunction with exercise

A cross-sectional, telephone-assisted survey was conducted on a sample of patients in North Carolina. 4,451 adults from 3,276 households reported a history of back or neck pain in the past few years. One adult from each household was selected, and 86 per cent completed the survey, resulting in 2,723 subjects. It should be noted that respondents and non-respondents to the survey were similar in age and race, but respondents were more likely to be male.

873 subjects had chronic LBP (with or without leg pain) or neck pain that was chronic (defined as at least three months’ duration, or more than 24 activity-
limiting episodes in the previous year). Questions regarding exercise prescription were adequately specific, including information on type of exercise (posture, stretching, strengthening etc.), practitioner, amount of supervision, and exercise parameters.

Study Strengths/Weaknesses:
The primary weakness of this study is the use of patient recall in the data collection. For example, in pre-trial piloting, some patients were unclear what “range of motion” exercises were. Further, it is possible that patient responses were subject to a social desirability bias.

This study does provide some valuable insight into the practice patterns surrounding exercise prescription. Future research should incorporate cohort study designs and alternative data sources, such as provider reports or claims data, while further exploring provider and patient characteristics that are associated with exercise prescription, and barriers to prescription and adherence.

For article with references, please go to www.cndoctor.ca