17-21
on stress.
Kxercise interventions have been shown in
some randomized clinical trials (RCTs) to help
prevent low back pain in at-risk populations.^^
However, tlie bulk of the scientific literature
indicates that specific back exercises (e.g.,
flexion, extension, and strengthening exercises) and instruction in standardized exercises (as advocated by many physical therapists) do not appreciably improve low back
pain prognoses.^"^'^"*
Although the results of observadona! studies have not been entirely consistent (e.g..
Kujala et al-^^), these investigations have produced evidence pointing to the benefits of
leisure-dme physical activity in preventing
low back pain or improving its prognosis.^**"'"
In addidon, various published guidelines"'^"
recommend that padents with acute low back
l>ain stay acdve, and a recent systematic review of RCTs provided corroboradon for sueh
a strategy. ''' Nevertheless, no published studies have followed a clinical popuiadon over
an extended period and collected setial data
Hurwitz etal.
Data Collection
At baseline, participants underwent physical examinations and completed questionnaires, yielding data on sociodemographic,
clinical, and psychosocial characteristics; pai-ticipadon in recreational physical activities;
and use of back exercises. Follow-up questionnaires addressed paiticipants' health aiid
functional status, low back pain intensity and
related disability, physical activity levels, and
use of back exercises. Details about patient
screening and enrollment and the treatment
and foltow-up protocols have been provided
elsewhere,''
Low Back Pain and Disability Measures
all analyses. Covariates included in the crosssectional models were age, gender, baseline
duration of low back pain, ntimber of previous episodes of pain, assigned treatment
jjroLip, social support, strategy for coping with
[lain, internal locus of control, baseline MHI-5
score, baseline outcome variable value, muscle strengthening and flexibility exercising,
and follow-up week. Back exercise estimates
were also adjusted for physical activity level,
and physical activi^ estimates were adjusted
lor back exercise.
In addition to this set of covariates, all longitucfinal (transition) models (first-order
Markov chain regression models^^') also included previous values of the pain or disability vanable and previous MHI-5 scores.
These models were used to examine associations between activity and exercise and subsequent levels of pain, disability, and psychological distress. Back exercise estimates were
atijiisted for previous physical activity level,
and physical activity estimates were adjusted
for previous baek exercise. Product terms representing interactions (deviations from multi[)licativity) of physical activities and back exercises with gender, age, treatment group,
baseline duration of low back pain episode,
and follow up week were included in preliminary models: however, because these estimated interactions were negligible, they were
excluded fiijm the final models.
RESULTS
Screening, Enrollment, and Follow-Up
Seiected Sociodemographic
Characteristics: UCLA Low Back Pain
Study, 1 9 9 5 - 2 0 0 0
Sample
Variable
{n-681),%
<30
9.4
30-49
40.2
50-69
32.2
>70
18.2
Gender
Male
48.0
Female
52.0
Race/ethnicity
White/non-Hispanic
60.4
Latino/Hispanic
29.8
Asian/Pacific Islander
4.5
African American/Black
2.8
Otber
2.5
Education level
High school Of less
29.6
Some college
39.5
Coiiege
30.8
Maritai status
Married/involved in relationship
71.6
Widowed/divorced/separated
183
Never married
10.1
Employment status
Employed fuli time
58.7
8.1
7.5
On leave/unemployed
Retired
25.7
8.1
Very good
37.0
Good
42.0
Fair/poor
12.9
27,6
0.1-10.49
21.9
10.5-25.9
25.5
>26
25.0
Cross-Sectional Associations
Sampie
(n-681)
Average Pain,''
OR (95% Cl)
Back DisaOiiity,'
Ofi (95% Cl)
Psychological Distress,"
OR (95% Ci)
Back exercise
26.1
Never
Seldom (<ld/wk)
1.00
1.48(1.09,2.00)
1.00
<3wk
1.49(1.14.1.94)
1.00
1.59(1.19,2.12)
1.00
1.05 (0.78,1.42)
3 wk-3 mo
15.6
2.13(1.63,2.79)
1.56(1.20,2.01)
1.85(1.44,2.38)
0.98 (0.77,1.25)
3mo-ly
11.6
2.12(1.57,2.85)
1.56 (1.18,2.06)
1.61(1.22,2.13)
0.95 (0,73,1.23)
>ly
46.7
1.00
0.78(0.55,1.09)
0.68(0,49,0.95)
0.62(0.44,0.87)
1.00
0.83(0.60,1.13)
0.63 (0.46,0.85)
1.00
0,72(0.52,1.01)
0.60(0.44,0.82)
0.48(0.35,0.66)
1.00
0.77(0.56,1.06)
0.68(0.50,0.91)
(0-24 scale)
<5,%
17.5
6-10,%
31.6
11-15,%
27.9
>15,%
23.1
Mean (SD)
10.9 (5.4)
Median
11
6.7 (2.1)
Median
4,6 (1.9)
Median
0
0.1-10.49
10.5-25.9
>26
0.72(0.52,0.99)
0.60(0.44,0.83)
Wore. OR- odds ratio; Ci - confidence intervai. Average back pain and most severe low back pain were defined as ratings of 2
or higher on a 0-10 numerical scaie; low back disat)iiity was defined as a score of 3 or above on the 0-24 Roland-Morris
Low Back Disabiiity Qjestionnaire: psychoiogjcal distress was defined as a mental health inden score of less than 76.
"Adjusted for age, gender, baseline duration of low back pain episode, number of previous iow back pain episodes, assigned
treatrrent group, social support, strategy for coping with pain, internai health locus ot control, baseline mental health index
score, baseline vaije of outcome variable, muscie strengthening and flexibility exercising, and follow up week. Back exercise
effect estimates were also adjusted for physical activity levei, and physicai activity effect estimates were adjusted for back
exercise.
''Adjusted for age, gender, baseline duration of low back pain episode, number of previous low back pain episodes, assigned
treatment group, social support, strategy for coping with pain, internal locus of control, baseline mental bealth index score,
baseline iow back pain and disability levels, muscle strengthening and flexibility exercising, and follow up week. Back exercise
effect estimates were also adjusted for physical activity level, and physical activity effect estimates were adjusted for back
Mean (SD)
Median
76.9
At ieast 1, %
History of iow back pain episodes, %
Yes
82.2
No
17.8
62.2 (24.6)
Median
65
41.3(40.1)
Median
25
Mean (SD)
100
Median
SF-36 mental heaith index score
Mean (SD)
71,2 (16.6)
Median
76
67.8 (18.0)
Median
70
1820
Peer Reviewed
disti'ess dunng the follow-up period. For example, relative to paiiicipants reporting no
physical activity, the odds of meaningful low
back disability were more tban halved ajnong
parfidpaiits in the top qumlile (>26 ME'IV
week) of recreationai pbysica] activity {0R=
0.48; 95% CI = 0.35, 0.66). No association
was detected between back exercise stalus
aiid confiiiTent psychological distress.
By contrast, after adjustment for tlie effects
of back exercise and other covariates, odds of
clinically significant low back pain and disability' decreased as reported physical activity
level increased (P<.05 for trend). For example, participants in the top quartile of recreational physical activity' (26 MI'Ts per week)
were less than half as likely as participants
reporting no physical activity to have experienced meaningful low back disability (0R=
0.48; 95"/ii CI = 0.35, 0.66). Similarly, odds
of psychological distress decreased as reported physical activity increased {P<.05 for
trend). Relative to physically inactive participants, the odds of being psychologically dis-
Hurwitz et al.
Average Psin,^
OR (95% Cl)
Back Disability,'
OR (95% Cl)
Psychoiogical Distress,''
OR (95% Cl)
1,00
1,00
1.00
1.00
1,78(1,23,2.59)
1,48(1,07,2,03)
1.32 (0,95.1.83)
0.87(0,65,1,17)
1.46 (1,10,1,95)
1,64(1,21,2,23)
1,48(1.14,1,93)
1.30 (0,97,1.73)
1,19 (0.91,1,56)
1,44 (L07,1.94)
0,93(0.72,1.20)
0.78 (0.59,1,03)
1.00
1.00
1,00
1.00
0,1-10,49
0.91(0.62,1.34)
0,95(0.69,1.32)
0,91 (0,64,1.29)
1.03 (0.76,1.39)
10,5-25.9
>26
0.85 (0.60,1,20)
0.82(0.57,1.17)
0.85 (0.63,1.15)
0,70 (0,50,0.97)
0,91(0,69,1.20)
0,82 (0.60,1.12)
0,69 (0.50,0.97)
0,75(0,55,1.01)
Note. Average back pain and most severe low back pain were defined as ratings of 2 or higher on 0-10 numerical rating
scales; disability was defined as a score of 3 or above cn the 0-24 RolanO-Morris Low Back Disability Questionnaire; and
psychological dratress was defined as a mental health index score of less than 76.
'Adjusted for age, gender, baseline duration of low back pain episode, number of previous lew back pain episodes, assigned
treatment group, social support, strategy for coping with pain, internal locus of control, previous muscle strengthening and
flexibility exercising, previous mental health index score, previous value of outcome variable, and follow-up week. Back
exercise effect estimates were also adjusted for previous physical activity level, and physical activity effect estimates were
adjusted for previous back exercise.
"Adjusted for age, gender, baseline duration of low back pain episode, number of previous low back pain episodes, assigned
treatment group, social support, strategy for coping with pain, internal health locjs of control, previous muscle strengthening
and flexibility exercising, previous low back pain and disability levels, previous mental health index score, and follow-up
week. Back exercise effect estimates were also adjusted for previous physical activity, and physical activity effect estimates
were adjusted for previous back exercise.
11 controlled clinical trials conducted in industrial settings,'"* tbe 3 investigations of exercise interventions were fbimd to demonstrate effects on preventing back pain or
work-loss days, and the researchers concluded that evidence for the effectiveness of
exercise was limited. However, the 3 studies
involved several methodological problems
that made interpretation of their results difficult A recent review of 39 studies involving
workers showed little association of leisure
time physical activity witb low back pain, although sedentary leisure activity was found to
be associated with an increased prevalence of
low back pain and related sick leave,''^
In a systematic review of exercise therapy
that identified 39 RCTs, the researchers concluded that specific hack exercises should
not be recommended for patients with acute
{12 weeks or less) or chronic (more than 12
weeks) pain but that exercise in general may
be beneficial as pail of an active r-ehabilitation program for chronic pain sufferers.^"^
They found (1) moderate evidence that flexion exercises are not effective in reducing
acute pain, (2) strong evidence that extension
exercises are not effective in redticing aaite
pain, (3) no evidence that flexion exercises
are effective in reducing chronic pain, (4) no
evidence that strengthening exercises are effective in reducing acute pain, and (5) strong
evidence that strengthening exercises are not
more effective than other types of exercise.^''
In a systematic review of 20 RCTs of physical
exercise and training interventions, the International Paris Task Force on Back Pain concluded that active physical exercise should be
promoted among patients with acute or
chronic pain and that no evidence exists to indicate the effectiveness of specific exercises or
the relative benefits of one exercise regimen
over another.^''
Consistent with those studies, our findings
suggest that specific back exercises may be
counterproductive and that restoration of normal functioning should instead be emphasized.'*'* Our results are also consistent with
cuirent guidelines for managing acute low
back pain that recommend low-stress aerobic
exercises such as walking and swimming. '^''
Recommendations to engage in physical activity appear to be appropriate for people with
chronic low back pain as well. Brisk walking
Hurwitz el al.
1822
Hurwitz et al.
our serial assessments involved a large population of low back pain sufferers, we were
able to conduct analyses that clearly delineated the temporal relations of exposures and
outcomes. Tlie stronger CTOSS-sectional than
longitudinal associations observed suggest
possible reverse causation, a problem inherent in inteiprefing estimates derived from
cross-secfional studies of physicai activity and
low back pain.**^
In summary, in a population of primary
care patients presenting with low back pain,
participation in recreational physical activities was inversely associated, both crosssectionally and longitudinally, with low
back pain, related disability, and psychological distress. In contrast, back exercise was
positively associated both cross-section ally
and longitudinally with low back pain and
related disability. These results suggest that
individuals with low back pain, ratlier than
being advised to engage in specific back exercises, should instead be encouraged to
focus on nonspecific physical activities to
help reduce their pain and improve their
psychological health. Because of the perception that physical acfivity could result in
pain persisting for a longer period and fear
of pain have been idenfified as possible factors keeping low back pain patients from
being physically active,"' clinicians may
want to reduce such barriers to patients
modifying their behavior
Contributors
E. [.. HurwLty. was responsible for study dcsigii. df vrlopnient of sludy hypulhescs. supervision of data c()llectjon
and analysis, and drafting of the articlr. 11. Morgcnstem
con til bu ted to study design, data interpiftation, and
critical revision of the article. C. Chiao contrihuted to
thp literature review and data analysis.
Acknowledgments
iliis sliidy was Tunded by grAn\s ln)m the Agency for
Ht-althraro Hosearcli anti Qualily (RIH HS07755) and
the SfJUtlicni CiiliPoniia University of 1 leallh Sciences.
K. 1.. Hurwitz was supported by a frranf from the National Center for Complementary and Alternative Medicine IK23 ATOOO55].
We are j^ateliil to fei Yn and I.ii-May Cliiang for
their assistance with data managemenl and statistical
analysis.
sive symptoms among older adults: an eight-yeai" follow-up. Preu Med. 2000:30:371-380,
15. Weyerer S, Kupfer B. Physical exercise aJid |Tsychological health, Spurts Med. 1994:I7:l()8-llfi.
16. Tucker LA. Physical fitnes.s and psychological distress. Int J Sport Psychol. 1990;21:185-201.
References
1. Hing i;, Middleton K. National Hospital AmbulaHiry Medical Can- Survey: 2002 outpatient dppartni<?nt summary. Adv Diilti Vital Jiealih Slal. Jtine 24,
2004:345.
2.
Barnes PM. Pnwell-Griner E. McFann K, Nahin
RL. Complementary and altemative medicine use
nmiinj; adults United States, 2002, Adv Data Vital
llmkh Slal. May 27, 2004:343,
21. Hurwitz HL. Do asthma and physieal inactivity inHuenee the associations of personal and Job stressors
mth perceived stress and depression? Findings fnmi
the 1998-1999 California Work and Health Survey
Ann Epidemiol. 2003;13:358-368.
22. Linton SJ, van Tlildei- MW. Preventive interventions lor back and neck pn)hlcms: what is the evidence? Spine. 2001,2(1:778-787.
23. van Tulder M, Malmivaara A, Ksmail R, Koes B.
F.xereise therapy for low hack jiaiii: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine. 2000;25:2784-2796.
24. Abenhaim L, Rossignol M. Valat JP, et al. The role
o!" activity in the therapeutic management of back pain:
report of the international Paris Task Force on Back
i'ain. Spine. 20t}0:25(suppl 4):1S-33S.
36. Strong J. (\sliton R, Chant D, Pain intensity measurement in chmnic low hack pain. Clin j Pain. 1991:7
209-218.
37. Rolaiid M. Mtirris R, A study of the natural history of back painpait I: development of a reliable and
sensitive measure of disability in low back pain. Spine.
1983:8:141-150.
38. Doyo RA. Compaj-adve validity of Sickness Impact
Profile and shorter scales for functional assessment in
low hack pain. Spine. 198(i:ll:95l-934.
39. Jensen MP. Strom SF,, Turner JA, Romano JM, Validity of the Sickness Impact I'nilTle Roland scale as a
measure of dysHmction in chronic pain patients. Pain.
1992:50:157-162,
40. Deyo Ry\, Centor RM. Assessing responsiveness f>f
ftinctiona! scales to clinical change: analogy to diagnostic test performance-y C/imn!f Dis. 1986:39:897-906,
2(S. Leino P. Does leisure time physical activity prevent low back disorders? A prospective study of metal
industiy employees. Spine. 1993:18:863-871.
27 Harre^hy M. Kjer J, Hesselsoe G, et al. Kpidemiological aspecLs and risk factor for low back pain in 38year-old men and women: a 25-year prospective cohort study of (i40 school children. Eur Spine J. 199Ci:5:
312-318.
43. Bouter LM, van Tulder MW, Koes BW, N!ethodologic issues in low back j}ain research in primary care,
Spme. 1998:23:2014-2020.
RESEAn.,
1824
Peer Reviewed
Case Studies in
Public Health
Ethics
By Steven S. Coughlin, PhD, Colin L
Soskolne, PhD, and Kenneth W.
Goodman, PhD
ORDER TODAY!
American Public Health Association
Publication Sales
Web: www.apha.org
E-mail: APHA@pbd.com
Tel: 888-320-APHA
FAX: 888-361-APHA
ETOI
Hurwitz et al.