An Internet Internet‐mediated mediated Exercise Exercise Interven

Interven

Veterans with Chronic Low Back P

Sarah L. Krein, PhD, RN

J 2012 une 5, 2012

Ann Arbor VA Health Services Research

and Development Development Center of Excellence Excellence and

the University of Michigan

Funded by VA HSR&D Service IIR 07 by VA HSR&D Service IIR 07-177 
Overview

• Background • Conceptual Framework Conceptual Framework • Intervention • Study Aims/Design • 6 Month Study Findings 6 Month Study Findings• Implications 
Low Back Pain Low Back Pain

• Prevalent health condition 

– 1/4 adults in the U.S. re

portinglow ba

in the past three months 

– 1/2 reporting back pain during a give

1/2 reporting back pain during a give

(Deyo, 2006; Brooks, 2006; Law

• Costly • Significant negative consequences Significant negative consequences 

regardless of age 
Chronic Pain Amon

g

VA Primary Care Patien

• 50-70% of VHA patients in primary care 

chronic pain (Kerns et al., 2003; Clark, 2002; Butchart, 2009

• The prevalence may be higher (75%) a

female Veterans (Haskell et al., 2006) 

• Pain is among the most costly disorders 

in VHA settin

gs; total estimated costs 

attributable to low back pain was $2.2 b

FY99 (Yu et al., 2003) 

• Number of Veterans with chronic low ba

is growing steadily (Sinnott & Wagner, 2009) 
Strategies for 

Managing Chronic Back P

• Pharmacotherapy• Surgery and other interventional strate• Exercise Exercise therapy therapy, intensive intensive multidiscip

multidiscip

programs, and certain psychological

i t n erventions
What type of non-pharmacologic strategie

primary care patients report using to manaprimary care patients report using to mana

chronic pain?

70 50 60 30 40 10 20 

0 
VA/DoD Low Back Pain Clinical Practice Guide

Joint Clinical Practice Guideline from the Joint Clinical Practice Guideline from the 

American College of Physicians and the American Pa

• Recommendation 7: For patients w

not improve with self not improve with self-care options care options, 

clinicians should consider the addit

nonpharmacologic therapy with prononpharmacologic therapy with pro

benefits – for acute low back pain, 

manipulation; manipulation; for chronic or subacu

for chronic or subacu

intensive interdisciplinary rehab, ex

therapy, acupunc

t ure, massage, sp

manipulation, yoga, CBT or progrerelaxati on. 

(Chou et al., Ann Intern M
What do we know about the evid

• Suggests that exercise therapy is at least 

effective as other conservative thera

pies 

to moderately superior to no treatment or although, 

• St di ll d d l St

udies generally gra

d

e

d as low quality 

• Inconsistency in outcome measures 

• Heterogeneity Heterogeneity 

– Study populations – Exercise intervention Exercise intervention 

(Chou et al., Ann Intern Med, 2007; Hayden, Ann Intern Med, 2005; v

Spine J, 2006; van Middlekoop Eur Spine J, 2011) 
Exercise Therapy Define

Exercise Therapy Define

‘‘a series of s

pecific movements wit

of training or developing the body a practice or physical training to prompractice or physical training to prom

physical health’’ 

Van Middelkoop, Eur S
Exercise Therapy Exercise Therapy

Supervised exercise program 

home regimen ranging from home regimen, ranging from 

aimed at general physical fitnaerobic exercise to those aimmuscle strengthening, flexibilstretching 
Characteristics Associated with Improvemen

& Function for Chronic Low Back Pa& Function for Chronic Low Back Pa

• Individually designed Individually designed • Supervised (e.g., home with regular the

follow

-up or individually supervised) up or individually supervised) 

• Adherence to achieve high dose or hig

intensity intensity 

(

≥ 20 h) 

• Stretching (for pain) and strengthening 

function) function) 

(Hayden et al., Ann Intern Me
What is the Best Type of Exercis

Therapy for Low Back Pain? Therapy for Low Back Pain?
Summary Summary 

• Chronic back pain is prevalent Chronic back pain is prevalent • Patients use many different strateg

manage chronic pain including som

may not be recommended 
t 

t t t

Summary Cont. Summary Cont.

• Exercise is a key com ponent in the mana

people with chronic back pain (as well as other chronic conditions) not to mention 

another VA study found that . . . 

“A Little Regular Exercise Extends Men’

Washingtonpost com JaWashingtonpost.com, Ja

• M t os eff ective exercise regimen and h ow 

effectively and efficiently assist people w

exerci h i till b d i d ise therapy is still to be determined 
Veterans Walk to Beat Back Pa

Veterans Walk to Beat Back Pa

VA HSR&D IIR 07-177
Conceptual Framewo

Conceptual Framewo

Krein, BMC Musculoskeletal Dis
Walking

• Requires little skill or training • Low cost Low cost – walking shoes walking shoes 

• Most people can do it • Low injury rate 

• Physical activity of choice for adult

Physical activity of choice for adult

• Easy to objectively monitor 
Enhanced ( p g

uploading

Pedometer 



Specific Aims Specific Aims

• Aim 1 To determine whether a pedometer-based In

mediated intervention reduces pain mediated intervention reduces pain 

-related function

related function

interference among patients with chronic back pain term and over a 12-month timeframe. 

• Aim 2 To assess the effect of the intervention on w

(measured bystep counts

), qualit

y of life, pain inte

related fear, and self-efficacy for exercise. 

• Aim 3 To identify factors associated with a sustaine

To identify factors associated with a sustaine

walking over a 12-month timeframe among patients to the intervention. 
Recruitment and Eligibility Crite

• Provider referral to back class or two or 

outpatient encounters in the prior 12 mooutpatient encounters in the prior 12 mo

diagnosis of back pain with no neurolog(ICD-9-CM codes 724.2, 724.5, 846.0-8

– 1) persistent back pain > 3 months; – 

2

) sedentar

y lifest

yle 

(< 150 minutes of 

p

activity per week); 

– 3) at least weekly access to a computer 

port and Internet access; 

– 4) able to walk at least one block. 

Study Outcomes Study Outcomes

• Primary outcome is pain

‐related funct

interference

– Roland and Morris Back Pain Disability

Questionnaire Questionnaire (RDQ) index

– MOS pain and function

• Secon

dary outcomes

– average daily steps, general health

‐relate

of life, pain intensity, pain

‐related fear o

kinesiophobia, depressive symptoms
Data Collection Data Collection

• Survey

– Baseline–

6 months

– 12 month

•

6 minute walk test

• Pedometer Pedometer data and website website use• Electronic medical record data (utiliza

VA healthcare services, medications)

•

Qualitative interviews
Assessed for Eligibility

(n = 1412)

R d an omized (n

= 229)

Intervention Control

(n = 111)

Control

(n = 118)

6 Months 6 months

(n = 101) (n = 106)
Baseline Characterist

Baseline Characterist

Variable Control Age (mean, SD) 51.9 (12.8) Gender (% male) 86 

General Health Status (% fair or poor) 42.7 Depressive symptoms score (mean, SD) 13.8 (6.6) 

Report take narcotic medications (%) 48.7 

Em

p y lo

yment status (% em

p y lo

yed) 30.5 

Roland

‐Morris Disability score (mean, SD) 9.8 (5.7) 

Pain severity severity last

4 weeks (mean, SD) 6 1. (1.6) 

Step Counts (mean, SD) 4228 (2239) 
6 Month Preliminary Result

Complete Case Analysis

Variable Control Intervention Adj dif

f

Roland

‐Morris

Disabilit

y score

9.2 (5.5) 7.2 (5.6) 1.53 

y

Pain effects 43.6 (18.1) 37.6 (19.5) 3.60 

Pain severity 5.1 (2.1) 4.7 (2.1) 0.48 Exercise self

‐

efficacy

5.7 (2.5) 6.7 (2.4) 0.81 

Fear avoidance

l

14.0 (5.9) 13.2 (6.0) 0.63 

scale

Avg. step counts 4455 (2988) 5107 (3125)

‐ 

*P-value for difference between groups, adjusted for baseline 
r a e va ue 

6 Month Preliminary Result

Adjusted for Non-response 

Variable Adjusted Adjusted P l Adjusted 

difference

P‐value Adjusted

difference

Roland > 4

Rol d an ‐Morris

Disabilityscore

1.24 0.09 1.99 

Pain effects 2.56 0.25 4.83 Pain severity 0.51 0.06 0.62 Exercise self‐efficacy

0.66 0.03 0.64 
Conclusions

Patients in the Internet mediated interv

com

pared with those in the control

grou

reported less back pain related disability increased increased their physical physical activity activity (walking

(walking

6

‐months following study enrollment.

Intervention Intervention patients patients also reported reported less 

improvements in general pain

‐related fu
t t t t

t t

Implications

• A facilitated walking intervention that use

enhanced pedometer and the Internet m

important strategy for enhancing managand improving access to an eff ective exe

program for Veterans with chronic back 

• This type of primarily automated interve

could be an efficient way of delivering or supp lementing care provided through tra

facility based programs.
Would you have tried walking to 

manage your back pain?

“ pro

b bl a

y not. Now, yes. But

t

hen, I d 

know what the study or the walking c

for me. But I do now . . . I had

a lot of 

pain, that’s why I was in the study. Anseemed to alleviate my back pain. In 

credit it to the walking, and the true t

when I had to go off the program becamy illness and the back pain returned

just up until recently, when I had resu

walkin

g.”
Study Team Study Team 

• Caroline Richardson

• Bob Werner

• Reema Kadri

• Jack Rosenber

• Maria Hughes

• John Piette

• Tabitha Metreger

• Eve Kerr

• Myra Kim

• Bob Kerns

• Rob Holleman

Thank you to the VAAAHS Physical Therapy Dep
Thank You!

Sarah.krein@va.gov