Research Review By Dr. Michael Haneline©

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Date Posted:

December 2017

Study Title:

Contemporary biopsychosocial exercise prescription for chronic low back pain: questioning core stability programs and considering context

Authors:

Stilwell P & Harman K

Author's Affiliations:

Dalhousie University, Halifax, Nova Scotia, Canada.

Publication Information:

Journal of the Canadian Chiropractic Association 2017; 61(1): 6-17.

Background Information:

There have been many advances in the care of patients with low back pain (LBP), including improved imaging techniques, technology, and passive interventions. Even so, the prevalence of LBP continues to increase and the condition has become the leading cause of disability worldwide (1).

After receiving care from a general practitioner or chiropractor, many LBP patients report that they still have pain a year later, and up to 73% will have another episode of LBP within that timeframe (2).

Persons with chronic low back pain (CLBP) – that is, pain for greater than three months – have a gloomier outlook, with 60-80% of those seeking help still reporting LBP past one year.

Considering how burdensome LBP has become to individuals and society, and how resistant CLBP is to treatment, the authors of this paper aimed to explore the effectiveness of treatments for CLBP, particularly, commonly prescribed exercise programs.

Exercise for CLBP:

Exercise has been shown to an effective intervention for CLBP that not only reduces pain and improves function, but can also effectively prevent LBP. Exercise is safe, cost-effective, evidence-informed, and can be used as a self-management strategy outside of the clinical environment.

One of the main problems with prescribed exercise for CLBP is that only a small percentage of patients follow through with a program, which leads to poor outcomes. The most common reasons given by CLBP patients for poor adherence to exercise is diagnostic uncertainty and fear of pain or harm from performing the exercise (3).

Clinicians typically prescribe exercises for CLBP targeting specific elements of the musculoskeletal system, with the hope of making physical changes that improve biomechanics. However, the evidence suggests that such changes, though they often occur, do not correlate very well with meaningful clinical outcomes. The authors, therefore, ask the question: “What type of exercise to prescribe?”

In a systematic review of exercise therapy for non-specific CLBP, it was reported that improvements in pain and function are not directly attributable to changes in the musculoskeletal system (e.g., muscle strength and endurance, and mobility) (4). These findings argue against the notion that exercise programs that target core stability and neuromuscular control are crucial in CLBP rehabilitation. Furthermore, a Cochrane systematic review that considered studies of motor control exercises for non-specific CLBP reported that no form of exercise is superior to others (5). Other studies have reported similar findings!

The authors point out additional shortcomings of core strengthening exercises for CLBP, including the idea that this approach may create rather than reduce negative perceptions about the patient’s back condition. A 2014 systematic review (6) reported that core stability exercises were not more effective than other types of exercise regarding long-term pain and disability, and that informing the patient that they lack core stability, which therefore needs to be strengthened, could increase fear-avoidance.

A Biopsychosocial Approach:

The authors suggest that rather than prescribing targeted exercises for CLBP, it may be better to teach patients exercises using a biopsychosocial approach that considers the patient’s perceptions and self-identified functional goals. Since one of the most important aspects of a successful exercise program is that the patient adheres to the program, it makes sense to encourage them to participate in a type of exercise that they enjoy and expect will help them (e.g., walking in nature, tai chi, yoga, etc.).

Exercise programs that are commonly used in clinical practice are based on a patho-anatomic model (e.g., core stability exercises for CLBP) which may be difficult for clinicians to abandon. However, given the current biopsychosocial understanding of pain, tissue-based approaches that consider only one aspect of CLBP appear to be unfounded and outdated.

There is also evidence that core stability exercises may be misguided because people with LBP already have increased levels of abdominal and lumbar muscle activity, which leads to increased trunk stiffness that persists even after symptoms improve.

The authors suggest that CLBP patients may have better results if instructed to perform trunk muscle relaxation with movement, instead of trunk muscle activation. EDITOR’S NOTE: this is an interesting idea, but I feel instruction of this nature must be administered on an individual basis, arising from consideration of the entire clinical scenario for a given patient.

Furthermore, the way core stability exercises are prescribed may be problematic in that negative perceptions about the patient’s back may be created. For instance, telling a patient that they have ‘weak back muscles’ that need to be strengthened to support their ‘unstable spine’ can make them feel fragile and vulnerable, which could increase fear-avoidance.

The Context of Exercise Prescription

When working with patients, clinicians (whether they know it or not) create a context that can have a positive influence on the condition beyond the effect of the treatment, referred to as the placebo effect. On the other hand, a negative context can lead to poorer outcomes, which is known as the nocebo effect.

The term placebo has historically been thought of as something inert, fake, or non-specific, and a superfluous or even undesirable aspect of the patient encounter. Clinicians have more recently been advised to recognize the contextual elements of treatment and their positive (and possibly negative) effects. It has even been suggested that a new non-stigmatized term be used to replace placebo effect, such as ‘contextual healing’ (7). Negative communication with patents and resulting nocebo effects appear to be even more important factors to consider in pain patients than placebo effects.

Five Common Contextual Factors to Consider:
  1. The therapeutic alliance: Defined as “a trusting connection and rapport established between therapist and client through collaboration, communication, therapist empathy and mutual understanding and respect”. The clinician reassures the patient that their condition is manageable, not focusing on their physical defects.
  2. Education: This has the potential to elicit both placebo and nocebo effects. Clinicians should be careful to avoid giving the patient the impression that they are to blame for their condition, which can engender nocebo effects. For instance, telling a patient they are lifting incorrectly or that they have an unstable spine. The authors suggest two pain neuroscience education resources as being useful for patient education: Explain Pain (8) and Therapeutic Neuroscience Education (9).
  3. Expectations of therapeutic success or failure: If a patient expects a positive result from a treatment, the likelihood that they will experience a positive result from that treatment is much stronger. On the other hand, faulty communication that produces negative patient expectations can lead to poorer treatment results.
  4. Attributions of therapeutic success or failure: Attributions are an individual’s understanding of why things occurred the way they did, which helps shape their expectations for future similar circumstances. Therefore, it is important to facilitate a patient’s positive beliefs about their back to empower them in the future.
  5. Mastery or cognitive control over a problem: Mastery is when a person has control over circumstances that have a significant effect on their life. For example, when a CLBP patient learns and believes that they can overcome their challenging movement tasks, which increases their self-efficacy and leads to mastery. Furthermore, if a patient expects an exercise to reduce pain and improve function, they are more likely to do it, as well as to derive more benefit from it via the placebo effect. Conversely, if a patient’s expectations are negative, they will be less likely to comply and less likely to derive benefit.

Clinical Application & Conclusions:

Clinicians will be able to utilize the information presented in this paper in their practices immediately, especially the part about presenting a patient’s clinical case in terms of positive reassurance, rather than focusing on their physical defects and blaming them for being in the condition they’re in.

No doubt some RRS readers will be resistant to abandoning established practices, such as core-strengthening exercises, in favor of letting the patient choose exercises they will actually follow through with. However, the evidence that was presented on this point seems to be convincing.

It is important for clinicians to recognize that the placebo effect is a factor in almost every aspect of patient care and it should be used for the patient’s benefit. Numerous studies have shown that negative comments and actions may have nocebo effects that have the potential to strongly worsen patient outcomes. Therefore, scaring patients into treatment compliance is almost never a good option.

Study Strengths / Weaknesses

This was a narrative report that did not utilize a systematic process for locating, evaluating and reporting the evidence (as would be done in a systematic review, for example). Nevertheless, this paper is very informative and based on sound evidence that is presented in an unbiased manner.

The authors admit that more research is needed in this area, specifically to examine the interplay between biological, psychological, and social factors and their impacts on individuals with LPB.

Additional References:

  1. Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 386(9995): 743-800.
  2. Kongsted A, Kent P, Hestbaek L, et al. Patients with low back pain had distinct clinical course patterns that were typically neither complete recovery nor constant pain. A latent class analysis of longitudinal data. Spine J 2015; 15(5): 885-894.
  3. Slade SC, Patel S, Underwood M, et al. What are patient beliefs and perceptions about exercise for nonspecific chronic low back pain? A systematic review of qualitative studies. Clin J Pain 2014; 30(11): 995-1005.
  4. Steiger F, Wirth B, de Bruin ED, et al. Is a positive clinical outcome after exercise therapy for chronic nonspecific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. Eur Spine J 2012; 21(4): 575-598.
  5. Saragiotto BT, Maher CG, Yamato TP, et al. Motor control exercise for chronic non-specific low-back pain. Cochrane Database Syst Rev 2016; 1: CD012004.
  6. Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord 2014; 15: 416.
  7. Miller F, Kaptchuk T. The power of context: reconceptualizing the placebo effect. JRSM 2008; 101(5): 222-25.
  8. Butler DS, Moseley G. Explain Pain. Adelaine City West: Noigroup Publications, 2003.
  9. Louw A, Puentedura E. Therapeutic neuroscience education: teaching patients about pain: a guide for clinicians. International Spine and Pain Institute, 2013.