# Exercise as it relates to Disease/Do Stretching Exercises Help Reduce Lower Back Pain?
## Do Stretching Exercise Help Reduce Lower Back Pain

This Wikibooks page is a critique of the journal article Effectiveness of a Stretching Program on Low Back Pain and Exercise Self-Efficacy Among Nurses in Taiwan: A Randomised Clinical Trial.

### What is the background to this research?

Chronic lower back pain is a major cause of disability worldwide. It can involve fatigue, discomfort, or pain in the back and legs. A specific diagnosis is difficult, and the duration of symptoms and pain levels are very individualised. It has a major impact on an individual’s quality of life, affecting their ability to sit, stand, walk and sleep. Triggers for lower back pain (LBP) may include:
* inactivity
* excess weight
* bad posture
* poor ergonomics in the work place
* repetitive/physically demanding tasks
LBP has physical, economic, psychological, social and recreational consequences. In the workplace, it affects service delivery, productivity and absence levels.
Research predicts more than 50% of adults will experience LBP, and therefore effective treatments are essential. Treatments include medication, manipulation, exercise and surgery. Exercise is a common treatment of LBP and has been shown to be effective. The challenge is finding a treatment that targets the individual’s LBP as the effectiveness of ‘a one size fits all’ program is questionable.
While exercise helps, individuals need to stick to an exercise program to achieve the benefits. Managing barriers to exercise, like lack of time and not knowing what to do, is key. In research this is defined as exercise self-efficacy and is referred to as the level of self-confidence in overcoming barriers to complete an exercise program.
This study focused on nurse’s susceptibility to a LBP injury due to continuous bending and lifting and very long hours of standing and tests if a structured and scheduled stretching program can lead to beneficial outcomes.

### Where is the research from?

This study was conducted in Taiwan by three researchers affiliated with:
* Chung Hwa University of Medical Technology;
* Kaohsiung Medial University;
* National Cheng Kung University; and
* The University of Michigan in Michigan.
It was published by the American Society for Pain Management Nursing in 2014.
Variations in nursing practices and working conditions should be considered if applying recommendations to other occupations or in other countries.

### What kind of research was this?

Researchers used a randomised clinical trial to conduct original research which is frequently used in nursing studies. Given that the study was limited to nurses and not the general population, this is seen as a convenience sample, and should be carefully considered if extending results to the wider population.
Nurses were eligible for the study if they had experienced LBP for six months and had a VASP (Visual Analogue Scale for Pain) above four. The VASP is a 10-point scale that describes pain ranging from ‘no pain’ to ‘worst possible pain’, with a score of 5 classed as moderate pain.
Of 185 applicants, 127 were deemed suitable because their treatments did not include medication or surgery. Coincidently, a minimum sample size of 63 participants for each group was predetermined by a pilot study using the power analysis statistical method, a suitable method when testing statistical significance.

### What did the research involve?

Participants were randomly allocated to a stretching exercise program (SEP) group or a control group. Participants completed questionnaires regarding LBP intensity, frequency and treatment. VASP and exercise self-efficacy scores were calculated and this process was repeated at the 2, 4 and 6 month follow-up sessions.
The SEP was run for 50 minutes, 3 days a week after work, for 6 months. Delivered in an air-conditioned community health center, with music, by two trained research assistants, the session was supervised by an exercise professional.
The control group were instructed to perform ‘usual activities’.

### What were the basic results?

After 6 months, 81% of the SEP group reported moderate to high pain relief and lower VASP scores compared to the control group. This is consistent with other studies that found stretching exercises to be an effective treatment of LBP. Self-efficacy scores increased by 9% for the SEP group and marginally increased for the control group. Other studies have shown that improvements in self-efficacy during a LBP rehabilitation program were predictive of lower self-reported pain after 6 months. Researchers attributed improvements to:
* ‘face to face’ interventions being more effective than web-based interventions
* long term follow up of 6 months being more effective than 6 weeks. Other studies have also shown that interventions greater than 20 weeks are required for a reduction in lower back pain.
Though not discussed by the researchers in the results, 23 participants withdrew from the study. Reasons provided by participants are shown in the table below:
| Reasons for Participants Withdrawal for the Study | Stretching Exercise Program (number) | Control (number) |
| undesirable exercise program/study | 3 | 6 |
| physical discomfort | 5 | 1 |
| unable to co-operate | 3 | 1 |
Obviously, the SEP program did not meet the needs of all participants. Unlike other studies, the researchers did not acknowledge that patient needs vary and they may gain more benefit from individualised programs. In addition, specific tests to identify needs, limitations and preferences are essential.

### What conclusions can we take from this research?

Structured and supervised SEPs are effective treatments for LBP and result in increased exercise self-efficacy. However, the SEP would be improved with initial testing of participants and adjusting the program for individual needs.
The increase in exercise self-efficacy was attributed to the face-face delivery of exercise and follow-up sessions. However, due to costs-effectiveness, the researchers also suggest the program can be home based or delivered on-line, which contradicts these findings. Self-efficacy may have also improved because the SEP was conducted through the hospital that participants worked at and felt supported by their employer. A cost-benefit analysis of work-place exercise interventions compared to the economic costs of LBP like absenteeism, decreased service delivery and productivity may be an area for future research.

### Practical advice

* Individuals experiencing LBP may benefit from a structured and supervised SEP
* SEPs should be developed by an exercise professional, based on individual needs and limitations

### Further information/resources

Mediators of Yoga and Stretching for Chronic Low Back Pain. http://dx.doi.org/10.1155/2013/130818
Effects of Motor Control Exercise Vs Muscle Stretching Exercise on Reducing Compensatory Lumbopelvic Motions and Low Back Pain: A Randomized Trial http://dx.doi.org/10.1016/j.jmpt.2016.07.006

### References

* 1 2 3 4 5 6 Chen H-M, Wang H-H, Chen C-H, Hu H-M. Effectiveness of a stretching exercise program on low back pain and exercise self-efficacy among nurses in Taiwan: a randomized clinical trial. Pain management nursing : official journal of the American Society of Pain Management Nurses. 2014;15(1):283.
* 1 2 3 4 5 Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: exercise therapy for nonspecific low back pain. Annals of internal medicine. 2005;142(9):765.
* 1 2 3 4 5 Pedersen BK, Saltin B. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scandinavian Journal of Medicine & Science in Sports. 2015;25(S3):1-72.
* 1 2 3 Bi X, Zhao J, Zhao L, Liu Z, Zhang J, Sun D, et al. Pelvic floor muscle exercise for chronic low back pain. Journal of International Medical Research. 2013;41(1):146-52.
* 1 2 3 4 5 6 7 Tancred G, Tancred B. Implementation of Exercise Programmes for Prevention and Treatment of Low Back Pain. Physiotherapy. 1996;82(3):168-73.
* ↑ Mierswa T, Kellmann M. The influences of recovery on low back pain development: a theoretical model. International journal of occupational medicine and environmental health. 2015;28(2):253-62.
* ↑ Dagenais S, Caro JJ, Haldeman S. A Systematic review of low back pain cost of illness studies in the United States and internationally. Value in health. 2008;11(3):a160-a1.
* 1 2 de Beer LT. The effect of presenteeism-related health conditions on employee work engagement levels: A comparison between groups. South African Journal of Human Resource Management. 2014;12(1):1-8.
* ↑ Steiger F, Wirth B, de Bruin ED, Mannion AF. Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. European Spine Journal. 2012;21(4):575-98.
* 1 2 Fraser SN, Rodgers WM. The Influence of General and Exercise Specific Social Support on Self‐Efficacy for Overcoming Barriers to Cardiac Rehabilitation. Journal of Applied Social Psychology. 2012;42(8):1811-29.
* 1 2 3 Hayat MJ. Understanding Sample Size Determination in Nursing Research. Western Journal of Nursing Research. 2013;35(7):943-56.
* ↑ Gisla DE, Izaguirre MJ, Hopkinson SG. Using Evidence to Increase Compliance with Therapeutic Stretching for Chronic Low Back Pain. US Army Medical Department journal. 2015:31.
* ↑ Altmaier EM, Russell DW, Kao CF, Lehmann TR, Weinstein JN. Role of Self-Efficacy in Rehabilitation Outcome Among Chronic Low Back Pain Patients. Journal of Counseling Psychology. 1993;40(3):335-9.