By Ceara Higgins, DC (for RRS Education)
Study Title: The effectiveness of walking versus exercise on pain and function in chronic low back pain: a systematic review and meta-analysis of randomized trials
Authors: Vanti C, Andreatta S, Borghi S, et al.
Publication Information: Disability and Rehabilitation 2017; 5: 1-11. DOI: 10.1080/09638288.2017.1410730
Low back pain (LBP) is a significant cause of activity limitation and absence from work and has been associated with high levels of economic burden.1 While 90 percent of patients return to pre-injury activities within two months, the remaining 10 percent are at a high risk for developing chronic pain and disability.2 Current guidelines for the management of chronic low back pain (CLBP) suggest staying as active as possible and even increasing levels of physical activity,4 as reduced mobility can cause significant decreases in quality of life and overall health status.3 Walking can increase cardio-respiratory capacity, maximum oxygen uptake and endurance with a low risk of injury.5 As well, it is simple, accessible, and free. This review aimed to provide an up-to-date, specific systematic review and meta-analysis in order to determine the effectiveness of walking compared with other forms of physical exercise on pain, disability, quality of life and fear-avoidance in patients with CLBP.
Five studies were selected, and their data pooled via quantitative synthesis for meta-analysis. The studies included a total of 329 subjects, with an average age of 43 years. Thirty-one participants reported adverse effects, including 14 with the flu or other medical conditions, two allergic reactions, one road traffic collision, one lateral ankle sprain, six reporting increased pain in the lower limbs, and seven reporting increased LBP.
Walking vs. Exercise:
Two studies assessed pain in the short term (within 3 months after the intervention), mid-term (3-6 months), and long-term (6-12 months).9-10 In all cases, the overall effect size of walking (compared to exercise) was small and not significant (yet, both treatments were helpful). Three studies assessed disability in the short term,9-11 and two studies assessed disability in the mid- and long-term.9-10 Again, in all cases, the overall comparative effect size was very small and not significant (again, both interventions were effective). Two studies9,10 assessed disability in the mid- and long-term, finding very small and non-significant overall effect sizes; and two studies10,11 assessed short-term fear avoidance, also finding the overall effect size of walking to be very small and not significant compared to other exercise.
Combined Walking and Exercise vs. Exercise Alone:
Two studies12,13 assessed pain and disability in the short term and found small and insignificant overall effect sizes when comparing these interventions.
Clinical Application and Conclusions
For patients with chronic low back pain, walking was found to be equally as effective as intensive exercise on all chosen outcome measures at short-, mid-, and long-term follow up. Similar effects were seen in pain and disability when walking was added to exercise. A reduction was seen in pain, disability and fear avoidance beliefs, and an improvement was seen in perceived quality of life with both walking alone, walking combined with exercise, and exercise alone. There was a slight superiority in results for recovery of function with walking alone, and for reduction of fear-avoidance beliefs with exercise alone.
It is possible that studies with larger sample sizes or more intense training programs may provide different conclusions. All the selected studies utilized standardized walking and exercise dosages, thus it is possible that some participants were under- or over-dosed. Results were not significantly different when considering different numbers of sessions or type of walking.
While walking was not shown to have a greater effect than other physical exercise, it is known to induce positive changes on metabolism and improve psychological status.6 As well, walking programs have been shown to have similar levels of patient satisfaction as exercise and a high level of patient adherence.11 Finally, as walking programs carry lower costs than supervised exercise or physical therapy treatments,11 it can still be valuable in the treatment of individuals with CLBP.
The authors searched multiple databases from their inception to Dec. 31, 2016, with additional articles found through a manual search of the reference lists of relevant literature reviews. Two reviewers independently assessed title and abstracts and then full text of relevant articles for inclusion and exclusion criteria as outlined below. Any disagreement was resolved through discussion or by another author, as needed.
- Published randomized controlled trials (RCTs) with active controls or comparison groups including walking versus exercise and walking plus exercise versus exercise alone
- Studies including symptomatic adults (18 years of age or older) with a diagnosis of CLBP (pain for more than three months)7
- Studies including walking as a therapeutic intervention for CLBP or walking associated with any other form of exercise program
- Studies utilizing outcome measures for: 1) pain, including the Visual Analog Scale (VAS), a Numerical Pain Rating Scale (NRS), or other scoring measure for LBP; 2) disability, when the instrument used measured the impact of LBP on activities of daily living beyond work and leisure time activities; 3) lumbar function, including the Patient-Specific Function Scale (PSFS); 4) quality of life using the EQ-5 D scale; and 5) movement avoidance using the Fear-Avoidance Beliefs Questionnaire-Physical Activity Subscale (FABQ-PA)
- Quasi- and non-RCTs
- Studies including individuals with pain arising from scoliosis, tumors or other known pathologies
Two authors extracted the relevant data with a third author consulted in cases of disagreement. Two authors also judged the methodological quality of the studies using the PEDro scale.8 Two physical therapists assessed the selected studies for clinical relevance using the minimal clinically important difference (MCID) for each outcome based upon the literature.
Study Strengths / Weaknesses
- Clinical relevance of the changes was judged to be poor as only a few outcomes in a few studies reached the selected MCIDs.
- Included studies utilized different walking dosages and types, so the influence of these parameters cannot be assessed.
- It is possible that the selected studies may have underplayed, or not accounted for, confounding variables such as cardiac or respiratory conditions, weight-bearing abilities, and patient preferences, any of which may have affected the results.
- This review did not consider other outcome measures such as walking speed, muscular strength or aerobic capacity, which may have been impacted by the interventions and could be pertinent to individuals with CLBP.
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- Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ 2003; 81: 646-656.
- Quittan M. Management of back pain. Disabil Rehabil 2002; 24: 423-434.
- Vos T, Flaxman AD, Neghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2163-2196.
- Delitto A, George SZ, Van Dillen L, et al. Low back pain: clinical practice guidelines linked to the International Classification of Functioning Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2012; 42: A1-57.
- Hootman JM, Macera CA, Ainsworth BE, et al. Association among physical activity level, cardiorespiratory fitness and risk of musculoskeletal injury. Am J Epidemiol 2001; 154: 251-258.
- Hendrick P, Te Wake AM, Tikkisetty AS, et al. The effectiveness of walking as an intervention for low back pain: a systematic review. Eur Spine J 2010; 19: 1613-1620.
- Merskey H, Bogduk N. Classification of chronic pain: description of chronic pain syndromes and definitions of pain terms. Seatle (WA): IASP Press; 1994.
- Maher CG, Sherrington C, Herbert PD, et al. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 2003; 83: 713-721.
- Hartvigsen J, Morso L, Bendix T, et al. Supervised and non-supervised Nordic walking in the treatment of chronic low back pain: a single blind randomized clinical trial. BMC Musculoskelet Disord 2010; 10: 11-30.
- Hurley DA, Tully A, Lonsdale C, et al. Supervised walking in comparison with fitness training for chronic back pain in physiotherapy: results of the SWIFT single-blinded randomized controlled trial. Pain 2015; 156: 131-147.
- Shnayderman I, Katz-Leurer M. An aerobic walking programme versus muscle strengthening programme for chronic low back pain: a randomized controlled trial. Clin Rehabil 2013; 27: 207-214.
- McDonough SM, Tully MA, Boyd A, et al. Pedometer-driven walking for chronic low back pain: a feasibility randomized controlled trial. Clin J Pain 2013; 29: 972-981.
- Cho YK, Kim DY, Jung SY, et al. Synergistic effect of a rehabilitation program and treadmill exercise on pain and dysfunction in patients with chronic low back pain. J Phys Ther Sci 2015; 27: 1187-1190.