The effect of aquatic exercise program on low-back pain disability in obese women

Reporting and incorporation of social risks in low back pain and exercise studies: A scoping review

BACKGROUND

Exercise is a common intervention for low back pain, but its effect sizes are small to modest. Social risk factors significantly influence health outcomes, yet their consideration in randomized controlled trials on exercise for low back pain is often neglected. Determining their relationship to outcomes may provide better insight into exercise effectiveness.

OBJECTIVES

To assess the reporting of social risk factors (SRFs) in randomized controlled trials (RCTs) of exercise interventions for low back pain (LBP) in adults and explore associations between SRFs and outcomes.

DESIGN

Scoping Review.

METHODS

The databases MEDLINE, CINAHL and Cochrane were searched for studies published between January 2014 to March 2025. RCTs were included if exercise was the primary intervention for LBP treatment and had a minimum follow-up of 12 weeks. A planned analysis of SRF and outcome associations was not conducted due to insufficient data.

RESULTS

A total of 10,292 studies were identified and 157 studies included. Fewer than half (47.1 %) reported any SRFs at baseline. Socioeconomic position (42.7 %) was most frequently reported, followed by social relationships (17.8 %), race/ethnicity/cultural context (8.3 %), residential/community context (1.3 %), and gender (0.6 %). Four studies incorporated SRFs in their outcome analyses; one examined associations with outcomes and found no significant association.

CONCLUSION

SRFs are underreported in RCTs of exercise interventions for LBP and are rarely analyzed in relation to primary outcomes, limiting our understanding of their impact. Future trials should prioritize collecting and reporting SRFs at baseline and incorporating them in outcome analyses to assess their influence on outcomes.

Effects of a land and aquatic exercise-based program on pain, mobility and quality of life in patients with chronic low back pain: a study protocol for a randomized controlled trial

BACKGROUND

Chronic low back pain (CLBP) is a disease with significant functional, emotional and social impact. Several interventions are proposed for its management and exercise is one of main, land-based or water-based. This study describes a randomized controlled trial that will analyze the effect of a combined aquatic and land-based exercise program compared to an aquatic-based program on pain, functional incapacity and quality of life in adults with CLBP. Additionally, it will analyze the effects of exercise cessation in the same outcomes.

METHODS AND DESIGN

A blind randomized controlled trial will be developed with a 1:1 allocation ratio. Around 30 adults with mechanical CLBP will be randomly allocated in two groups. The experimental group (ALG) will complete an aquatic and land-based exercise program and control group (AG) will carry out only an aquatic program, both for 8 weeks. Participants will be assessed with Visual Analogue Scale, Oswestry Disability Index, Short-Form 36, Tampa Scale of Kinesiophobia-13 and Modified-Modified Schober Test, collected at baseline (M0), after 8 weeks (M1) and 4 weeks after the end of the intervention (M2).

DISCUSSION

This study may provide a relevant contribution to understand the potential effect of a combined land and aquatic exercise program on pain, functional disability, fear of movement, quality of life and lumbar mobility. The results may provide important information for CLBP management.

TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov (registration number: NCT06641570; date of registration: October 14, 2024).

Water-Based Exercise in Patients With Nonspecific Chronic Low-Back Pain: A Systematic Review With Meta-Analysis

ABSTRACT

Babiloni-Lopez, C, Fritz, N, Ramirez-Campillo, R, and Colado, JC. Water-based exercise in patients with nonspecific chronic low-back pain: a systematic review with meta-analysis. J Strength Cond Res 38(1): 206-219, 2024-This study aimed to systematically review and synthesize evidence (i.e., active [land-based training] and nonactive controls [e.g., receiving usual care]) regarding the effects of water-based training on patients with nonspecific chronic low-back pain (NSCLBP). Web of Science (WOS), PubMed (MEDLINE), EMBASE, EBSCO (SPORTDiscus; CINAHL), and PEDro were searched, with no date restrictions, until October 2021. The included studies satisfied the following criteria: (a) NSCLBP (≥12 weeks) patients, (b) water-based intervention, (c) control group (land-based trained; nonactive group), and (d) outcomes related to pain, disability, quality of life, or flexibility. The main outcome analyzed in the meta-analysis was pain intensity. Secondary outcomes included disability, body mass index, and flexibility. The random-effects model was used, and effect size (ES) values are presented with 95% confidence intervals (CIs). The impact of heterogeneity was assessed (I2 statistic), with values of <25%, 25-75%, and >75% representing low, moderate, and high levels, respectively. Alpha was set at p < 0.05. In conclusion, 15 studies (n = 524) were meta-analyzed. After intervention, pain intensity was reduced compared with nonactive controls (ES = -3.61; p < 0.001) and a similar reduction was noted when compared with land-based trained group (ES = -0.14; p = 0.359). Greater decrease in disability (ES = 2.15; p < 0.001) and greater increase in sit-and-reach (i.e., flexibility; ES = -2.44; p < 0.001) were noted after intervention compared with the nonactive group. In conclusion, water-based exercise therapy reduces pain intensity, disability, and increases flexibility in NSCLBP compared with nonactive subjects and was equally effective compared with land-based exercise to reduce pain. Favorable effects may be expected at ≤8 weeks. However, due to several methodological issues (e.g., high heterogeneity), for the improvement of most outcomes, we are unable to provide other than a weak recommendation in favor of intervention compared with control treatment.

Perturbation-based Balance Training in Adults Aged Above 55 Years with Chronic Low Back Pain: A Comparison of Effects of Water versus Land Medium - A Preliminary Randomized Trial

BACKGROUND

'Rapid balance reaction' or 'perturbation' training is an emerging paradigm in elderly back pain rehabilitation due to its connection to postural stability.

OBJECTIVE

This study aimed to inform the feasibility and practicality of perturbation-based balance training (PBT) using a stratification approach and to determine the effectiveness of land versus water-based PBT in elderly individuals with chronic low back pain (CLBP).

METHODS

Elderly CLBP participants (n=24) received exercise interventions as per treatmentbased classification (TBC) and were randomly allotted into water-based perturbation exercises (WBPE, Mean age=63.0±2.6years, n=12) and land-based perturbation exercise group (LBPE, 62.3±2.6 years, n=12). Pain intensity, disability, scores of fear-avoidance beliefs, fall efficacy, and rate of perceived exertion (RPE) were assessed before and at the end of 6 weeks.

RESULTS

WBPE group reported a significant reduction in pain score (median difference(MD)):2, p<0.03), fear avoidance behaviour for work (MD:9, p<0.01) and fear avoidance behaviour for physical activity (MD:10, p< 0.05), improved straight leg raise right (SLR) (MD:37.5°, p<0.05), and improved modified fall efficacy scores (MFES, MD:25, p<0.05) compared to the LBPE group at post-intervention. Within-group analysis in both groups revealed significant improvement in clinical outcomes except for fear-avoidance beliefs related to physical activity in the LBPE group. Subgroup analysis revealed that the high BMI elderly CLBP group of LBPE had significant improvements similar to the WBPE group except for scores of FABQ physical activity scores and SLR.

CONCLUSION

Possible key factors for future research are discussed in the realms of perturbation exercise in the elderly with CLBP.

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Structured Exercise Programs for Chronic Primary Low Back Pain in Adults

PURPOSE

Evaluate benefits and harms of structured exercise programs for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline.

METHODS

We searched for randomized controlled trials (RCTs) in electronic databases (inception to 17 May 2022). Eligible RCTs targeted structured exercise programs compared to placebo/sham, usual care, or no intervention (including comparison interventions where the attributable effect of exercise could be isolated). We extracted outcomes, appraised risk of bias, conducted meta-analyses where appropriate, and assessed certainty of evidence using GRADE.

RESULTS

We screened 2503 records (after initial screening through Cochrane RCT Classifier and Cochrane Crowd) and 398 full text RCTs. Thirteen RCTs rated with overall low or unclear risk of bias were synthesized. Assessing individual exercise types (predominantly very low certainty evidence), pain reduction was associated with aerobic exercise and Pilates vs. no intervention, and motor control exercise vs. sham. Improved function was associated with mixed exercise vs. usual care, and Pilates vs. no intervention. Temporary increased minor pain was associated with mixed exercise vs. no intervention, and yoga vs. usual care. Little to no difference was found for other comparisons and outcomes. When pooling exercise types, exercise vs. no intervention probably reduces pain in adults (8 RCTs, SMD = - 0.33, 95% CI - 0.58 to - 0.08) and functional limitations in adults and older adults (8 RCTs, SMD = - 0.31, 95% CI - 0.57 to - 0.05) (moderate certainty evidence).

CONCLUSIONS

With moderate certainty, structured exercise programs probably reduce pain and functional limitations in adults and older people with CPLBP.

An Adaptive Pedaling Assistive Device for Asymmetric Torque Assistant in Cycling

Dynamic loads have short and long-term effects in the rehabilitation of lower limb joints. However, an effective exercise program for lower limb rehabilitation has been debated for a long time. Cycling ergometers were instrumented and used as a tool to mechanically load the lower limbs and track the joint mechano-physiological response in rehabilitation programs. Current cycling ergometers apply symmetrical loading to the limbs, which may not reflect the actual load-bearing capacity of each limb, as in Parkinson's and Multiple Sclerosis diseases. Therefore, the present study aimed to develop a new cycling ergometer capable of applying asymmetric loads to the limbs and validate its function using human tests. The instrumented force sensor and crank position sensing system recorded the kinetics and kinematics of pedaling. This information was used to apply an asymmetric assistive torque only to the target leg using an electric motor. The performance of the proposed cycling ergometer was studied during a cycling task at three different intensities. It was shown that the proposed device reduced the pedaling force of the target leg by 19% to 40%, depending on the exercise intensity. This reduction in pedal force caused a significant reduction in the muscle activity of the target leg (p < 0.001), without affecting the muscle activity of the non-target leg. These results demonstrated that the proposed cycling ergometer device is capable of applying asymmetric loading to lower limbs, and thus has the potential to improve the outcome of exercise interventions in patients with asymmetric function in lower limbs.

Effects of non-pharmacological interventions on sleep in chronic low back pain: A systematic review and meta-analysis of randomised controlled trials

Low back pain is a leading cause of disability worldwide and adults with chronic low back pain (≥12weeks) commonly experience sleep impairments (e.g., insomnia, sleep disturbance). This study examined the effects of non-pharmacological interventions on sleep in adults with chronic low back pain. Six databases (PubMed, CINAHL, SPORTDiscus, PsycINFO, EMBASE, CENTRAL) were searched from inception to 2 June 2021 for randomised controlled trials. Pairwise random-effect meta-analysis estimated standardised mean difference (Hedges' g) at end-of-intervention follow-up. Nineteen studies (participants: 1348) were included. When compared to control, non-pharmacological interventions improved sleep (g [95%CI]: -0.33 [-0.56, -0.11], p = 0.004, small effect, I² = 59.3%; n = 879; studies: n = 13; GRADE: low). This small improvement in sleep was associated with a moderate reduction in pain intensity (-0.69 [-1.00, -0.38], p < 0.001, I² = 75.3%; n = 812; studies: n = 12; GRADE: very low) and no changes in back-related disability (-0.50 [-1.13, 0.14], p = 0.129, I² = 91.4%; n = 517; studies: n = 6; GRADE: low). Notably, all eligible studies reported interventions primarily aimed to reduce pain, although our search criteria were not limited to pain interventions. Key limitations were data paucity and high risk of bias. Future research should investigate sleep-based interventions (i.e., those purposely designed to improve sleep) using subjective and objective measures across a range of sleep domains (CRD42021275227).

Effect of aquatic physical therapy on chronic low back pain: a systematic review and meta-analysis

BACKGROUND

Chronic low back pain is a common musculoskeletal disease. With the increasing number of patients, it has become a huge economic and social burden. It is urgent to relieve the burden of patients. There are many common rehabilitation methods, and aquatic physical therapy is one of them. The purpose of this systematic review and meta-analysis is to summarize the existing literature and analyze the impact of aquatic physical therapy on pain intensity, quality of life and disability of patients with chronic low back pain.

METHODS

Through 8 databases, we searched randomized controlled trials on the effect of aquatic physical therapy on patients with chronic low back pain. These trials published results on pain intensity, quality of life, and disability. This review is guided by Cochrane Handbook for systematic reviews of interventions version 5.1.0. The level of evidence was assessed through GRADE.

RESULTS

A total of 13 articles involving 597 patients were included. The results showed that compared with the control group, aquatic physical therapy alleviated the pain intensity (Visual Analogue Scale: SMD = -0.68, 95%CI:-0.91 to -0.46, Z = 5.92, P < 0.00001) and improved quality of life (physical components of 36-Item Short Form Health Survey or Short-Form 12: SMD = 0.63, 95%CI:0.36 to 0.90, Ζ = 4.57, P < 0.00001; mental components of 36-Item Short Form Health Survey or Short-Form 12: SMD = 0.59, 95%CI:0.10 to 1.08, Ζ = 2.35, P = 0.02), and reduced disability (Roland Morris Disability Questionnaire: SMD = -0.42, 95%CI:-0.66 to -0.17, Ζ = 3.34, P = 0.0008; Oswestry Disability Index or Oswestry Low Back Pain Disability Questionnaire: SMD = -0.54, 95%CI:-1.07 to -0.01, Ζ = 1.99, P = 0.05). However, aquatic physical therapy did not improve patients' pain at rest (Visual Analogue Scale at rest: SMD = -0.60, 95%CI:-1.42 to 0.23, Ζ = 1.41, P = 0.16). We found very low or low evidence of effects of aquatic physical therapy on pain intensity, quality of life, and disability in patients with chronic low back pain compared with no aquatic physical therapy.

CONCLUSIONS

Our systematic review showed that aquatic physical therapy could benefit patients with chronic low back pain. However, because the articles included in this systematic review have high bias risk or are unclear, more high-quality randomized controlled trials are needed to verify.

Effectiveness of a Group-Based Rehabilitation Program Combining Education with Multimodal Exercises in the Treatment of Patients with Nonspecific Chronic Low Back Pain: A Retrospective Uncontrolled Study

Currently, there is no consensus on the best rehabilitation program to perform for nonspecific chronic low back pain (NSCLBP). However, multimodal exercises, education, and group-based sessions seem to be beneficial. We, therefore, launched such a treatment program and aimed to evaluate its effectiveness in improving patient health status. We retrospectively analyzed the records of 23 NSCLB patients who followed the MyBack program at La Tour hospital from 2020 to 2022 (25 sessions, 8 weeks). Patients were evaluated before and after intervention using pain on a visual analog scale (pVAS), Roland−Morris Disability Questionnaire (RMDQ), Pain Catastrophizing Scale (PCS), Tampa Scale of Kinesiophobia (TSK), and the EuroQol-5D-3L (EQ-5D-3L). Responder rates were calculated using minimal clinically important differences. Patients reported a significant reduction (p < 0.05) in the pVAS (5.3 ± 1.2 vs. 3.1 ± 1.6), RMDQ (8.8 ± 3.3 vs. 4.0 ± 3.7), PCS (24.5 ± 9.4 vs. 11.7 ± 7.9) and TSK (41.5 ± 9.2 vs. 32.7 ± 7.0). The EQ-5D-3L also statistically improved (score: 0.59 ± 0.14 vs. 0.73 ± 0.07; and VAS: 54.8 ± 16.8 vs. 67.0 ± 15.2). The responder rates were 78% for the pVAS and PCS, 74% for the RMDQ and TSK, and only 26% for the EQ-5D-3L. The MyBack program combining education with multimodal group exercises led to satisfactory clinical, functional, and psychosocial outcomes.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Comparison of Muscle Activation between Traditional, Diamond and Knuckle Push Up Among Trained Men

This study was conducted to compare the muscle activation during traditional, diamond and knuckle push up among trained men. Thirty men that had at least one year experience in fitness training involved as participants in this study. Participants were required to perform all the three kinds of push up in a randomised order to avoid bias effects in exercise order. Electromyography method was used to obtain the pectoralis major, triceps brachii and anterior deltoid muscle activation. Muscle activation was reported as percentages of maximal voluntary contraction. One way repeated measure analysis of variances (ANOVA) was conducted to compare the muscle activation between the three push up protocols. Results showed that the muscle activation of pectoralis major and anterior deltoid were highest during traditional push up while being the lowest during diamond push up. However, the muscle activation of triceps brachii was highest during diamond push up and lowest during traditional push up. As the conclusion, we can see that the position and distance of hands on the floor will give effects on the muscle activation. As the implication of this study, coaches, athletes and individuals can manipulate techniques while performing a movement to obtain more muscle activation to specific muscle of interest during a movement.

The short-term effects of balneotherapy on pain, disability and fatigue in patients with chronic low back pain treated with physical therapy: A randomized controlled trial

OBJECTIVE

This study aimed to compare whether there are positive effects of balneotherapy(BT) on pain, quality of life and disability of individuals receiving physical therapy(PT) for chronic low back pain and to examine the effect of body mass index(BMI) on treatment.

MATERIALS AND METHOD

This prospective, controlled, single blind study was conducted. Patients were randomized into two groups through a simple randomization in a 1:1 ratio. The clinician and biostatistics expert were blinded. PT group was applied PT, BT + PT group was applied PT + BT. All patients were included in the study for 3 weeks (total of 15 sessions, 5 days per week). All patients applied hot pack, transcutaneous electrical nerve stimulation and ultrasound. Patients in the BT + PT group applied BT in thermo mineralized water pool (20 min at 38-40 °C). Assessments were made using Pain-Visual Analog Scale(VAS), EQ-5D-3 L Scale(EQ5), EQ-VAS, Functional Assessment of Chronic Illness Therapy-Fatigue(FACIT-F), Roland-Morris Disability Questionnaire(RMDQ) and Quebec Back Pain Disability Scale(QBPDS) at the beginning (W0) and end (W3) of treatment. While performing statistical analysis, patients were divided into 3 categories of BMI1(18.5-24.9 kg/m²), BMI2 (25.0-29.9 kg/m²) and BMI3(≥30.0 kg/m²).

RESULTS

270 patients were randomized. 129 patients in PT group and 133 patients in PT + BT group completed the study. In the BT + PT group, there were increases in the EQ5 and EQ-VAS variables and decreases in all other variables compared to the PT group which were found to be statistically significant (for QBPDS p < 0.05, the others p < 0.01). The differences in all variables W0 and W3 were at least half reductions and increases which were found to be statistically significant (p < 0.01). In terms of BMI, there were significant differences for all groups, especially BMI3 had higher means for all variables apart from EQ5 and EQ-VAS than the other two categories. BMI1 was the BMI category with highest means for EQ5 and EQ-VAS. The Group × Time interaction was found to be statistically significant for Pain-VAS, EQ5, EQ-VAS, FACIT-F, QBPDS and RMDQ(p < 0.01). For Pain-VAS, the effect of the Group × Time × BMI interaction was found to be statistically significant(p < 0.05).

CONCLUSION

BT plus PT was more effective than PT. BT may have positive contributions to reducing pain, functionality of patients, quality of life, fatigue and disability status.