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Ben Ami N1, Chodick G2,3, Mirovsky Y4,5, Pincus T6, Shapiro Y7
1Ariel University, Physiotherapy, Ariel, Israel, 2Tel Aviv University, Epidemyology, Tel Aviv, Israel, 3Maccabi Healthcare Services, Epidemyology, Tel Aviv, Israel, 4Tel Aviv University, Medicin, Tel Aviv, Israel, 5Assaf Harofeh Medical Center, Orthopedics, Zerifin, Israel, 6Royal Holloway University of London, Psychology, London, United Kingdom, 7Ariel University, Health Science, Ariel, Israel
Background: Guidelines for Chronic Low Back Pain (CLBP) recommend physical activity (PA). However, increasing PA in CLBP patients has been shown to be challenging. Trials in populations with CLBP, ranging from psychologically informed physiotherapy, behavioral interventions, psychological interventions, and multidisciplinary interventions report only small to moderate effects that often are not maintained in the long term, Criticisms of current trials have suggested that there is a need for theory-driven interventions that focus explicitly on mechanisms underpinning key obstacles to recovery. Known obstacles to PA include low self-efficacy and fear avoidance.
The objective of the current intervention was to increase PA in people with chronic low back pain through a combination of theory-informed counseling based on behavior-change principles, and targeting of known obstacles to engaging with PA in this group of patients.
Purpose: The purpose of this trial was to examine the effectiveness of an Enhanced Transtheoretical Model Intervention (ETMI) aimed at increasing recreational physical activity in CLBP patients, against physiotherapy as usual in reducing disability.
Methods: A multicenter, prospective, controlled trial of patients with CLBP was conducted between February 2011 and July 2012 in Israel. We recruited males and females, aged 25-55 years, with CLBP, with or without radiation to the lower limb. Patients (n=220) referred to physiotherapy for CLBP were allocated to ETMI or to control. Across eight participating centers, there were 11 physiotherapists providing the treatment in the ETMI group and 23 providing treatment in the control group, all of whom had more than 4 years´ experience in practice.
The ETMI was delivered by physiotherapists and based on behavior-change principles, combined with increased reassurance, therapeutic alliance, and exposure to reduce fear avoidance. The primary outcome was back pain-related disability (Roland Morris Disability Questionnaire - (RMDQ)). Secondary outcomes included pain intensity, mental and physical health, and levels of physical activity.
Results: Intention to treat analysis in 189 patients at 12 months indicated that patients in the ETMI group had significantly lower disability compared to usual physiotherapy. The mean change from baseline difference between the interventions was 2.7 points (95% CI; 0.9, 4.5) on the RMDQ. At 12 months, worst pain, physical activity and physical health were all significantly better in patients receiving ETMI. The average number of sessions was 3.5 for the ETMI group and 5.1 for control.
Conclusion(s): Targeting obstacles to physical activity with an intervention comprising components to address self-efficacy and fear avoidance appears to be more effective than usual physiotherapy. The ETMI intervention appears to be a cost-effective intervention leading to improved outcomes for low cost.
Implications: Training physiotherapist´s to include behavior change techniques within their practice is feasible within a short time frame and results in considerable improvements in patients with chronic low back pain.
The novelty of this work is the integration of a theory-based model, ETMI, into a regular physiotherapy public system to increase PA.
Keywords: Transtheoretical model, Physical Activity, Chronic low back pain
Funding acknowledgements: The Maccabi Healthcare Services in Israel funded this research.
We thank the patients and physiotherapists, who participated in the study.
The objective of the current intervention was to increase PA in people with chronic low back pain through a combination of theory-informed counseling based on behavior-change principles, and targeting of known obstacles to engaging with PA in this group of patients.
Purpose: The purpose of this trial was to examine the effectiveness of an Enhanced Transtheoretical Model Intervention (ETMI) aimed at increasing recreational physical activity in CLBP patients, against physiotherapy as usual in reducing disability.
Methods: A multicenter, prospective, controlled trial of patients with CLBP was conducted between February 2011 and July 2012 in Israel. We recruited males and females, aged 25-55 years, with CLBP, with or without radiation to the lower limb. Patients (n=220) referred to physiotherapy for CLBP were allocated to ETMI or to control. Across eight participating centers, there were 11 physiotherapists providing the treatment in the ETMI group and 23 providing treatment in the control group, all of whom had more than 4 years´ experience in practice.
The ETMI was delivered by physiotherapists and based on behavior-change principles, combined with increased reassurance, therapeutic alliance, and exposure to reduce fear avoidance. The primary outcome was back pain-related disability (Roland Morris Disability Questionnaire - (RMDQ)). Secondary outcomes included pain intensity, mental and physical health, and levels of physical activity.
Results: Intention to treat analysis in 189 patients at 12 months indicated that patients in the ETMI group had significantly lower disability compared to usual physiotherapy. The mean change from baseline difference between the interventions was 2.7 points (95% CI; 0.9, 4.5) on the RMDQ. At 12 months, worst pain, physical activity and physical health were all significantly better in patients receiving ETMI. The average number of sessions was 3.5 for the ETMI group and 5.1 for control.
Conclusion(s): Targeting obstacles to physical activity with an intervention comprising components to address self-efficacy and fear avoidance appears to be more effective than usual physiotherapy. The ETMI intervention appears to be a cost-effective intervention leading to improved outcomes for low cost.
Implications: Training physiotherapist´s to include behavior change techniques within their practice is feasible within a short time frame and results in considerable improvements in patients with chronic low back pain.
The novelty of this work is the integration of a theory-based model, ETMI, into a regular physiotherapy public system to increase PA.
Keywords: Transtheoretical model, Physical Activity, Chronic low back pain
Funding acknowledgements: The Maccabi Healthcare Services in Israel funded this research.
We thank the patients and physiotherapists, who participated in the study.
Topic: Musculoskeletal: spine; Health promotion & wellbeing/healthy ageing; Pain & pain management
Ethics approval required: Yes
Institution: Maccabi Healthcare Services (MHS), a public health organization in Israel
Ethics committee: ethics committee of Maccabi Healthcare Services
Ethics number: 2008036
All authors, affiliations and abstracts have been published as submitted.
