Do Physical Therapists in the United Kingdom Recognize Psychosocial Factors in Patients With Acute Low Back Pain? Addition of telephone coaching to a physiotherapist-delivered physical activity program in people with knee osteoarthritis: A randomised controlled trial protocol Physical exercise, body mass index, and risk of chronic pain in the low back and neck/shoulders: longitudinal data from the Nord-Trondelag Health Study. Individualized vs. group exercise in improving quality of life and physical activity in patients with cardiac disease and low exercise capacity: results from the DOPPELHERZ trial Effect of workplace- versus home-based physical exercise on pain in healthcare workers: study protocol for a single blinded cluster randomized controlled trial A physiotherapist-delivered integrated exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a randomised controlled trial protocol Integrating Mobile health and Physical Activity to reduce the burden of Chronic low back pain Trial (IMPACT): a pilot trial protocol Effect of Individually Tailored Biopsychosocial Workplace Interventions on Chronic Musculoskeletal Pain and Stress Among Laboratory Technicians: Randomized Controlled Trial. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain Low back pain in general practice: reported management and reasons for not adhering to the guidelines in The Netherlands. Predictive factors of adherence to frequency and duration components in home exercise programs for neck and low back pain: an observational study Comparison of two physical exercise programs for the early intervention of pain in the neck, shoulders and lower back in female hospital staff. Graded Activity for Low Back Pain in Occupational Health Care Intelligent Physical Exercise Training in a Workplace Setting Improves Muscle Strength and Musculoskeletal Pain: A Randomized Controlled Trial Prevalence and impact of chronic musculoskeletal ankle disorders in the community. Decrease in musculoskeletal pain after 4 and 12 months of an aerobic exercise intervention: a worksite RCT among cleaners Supervised and non-supervised Nordic walking in the treatment of chronic low back pain: a single blind randomized clinical trial Effects of aquatic exercise on flexibility, strength and aerobic fitness in adults with osteoarthritis of the hip or knee. Point-of-care prognosis for common musculoskeletal pain in older adults. Massage for Low Back Pain: An Updated Systematic Review Within the Framework of the Cochrane Back Review Group The efficacy of an aerobic exercise and health education program for treatment of chronic low back pain. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care
Study Design . A cross-sectional , descriptive vignette survey of practicing , musculoskeletal physical therapists . Objectives . The aim of this study was to determine if musculoskeletal physical therapists , in the United Kingdom , recognize when patients with low back pain ( LBP ) are at risk of chronicity due to psychosocial factors . A secondary aim was to explore the advice they give to patients about  work and activities .  Summary of Background Data . Psychosocial factors have been shown to be important in the progression from acute LBP to chronic disability . Early identification of individuals at risk of developing chronic disability is important to enable targeted intervention . Methods . Three vignettes were written based on acute LBP patients attending for physical therapy  and incorporated into a self-completed postal question naire sent to a simple r and om sample of musculoskeletal physical therapists in the United Kingdom ( n = 900 ) . After one reminder , 20 % of nonresponders were sent a further question naire ( n = 80 ) . Data were analyzed using the Statistical Package for the Social Sciences ( SPSS version 11 ) . Results . The response rate was 57.7 % ( n = 518 ) with 453 meeting all inclusion criteria . The sample consisted of physical therapists working in the musculoskeletal field across all practice setting s. Most correctly rated the chronicity risk of the low- and high-risk patient vignettes . Advice to restrict work and activity was common . Conclusions . Most physical therapists recognize when patients are at high risk of developing chronicity , yet many recommend the patient limit their activity levels and not work . Advice to “ not work ” is associated with more severe perceived spinal pathology , suggesting persistence of the biomedical model for LBP Background Knee osteoarthritis ( OA ) is one of the most common and costly chronic musculoskeletal conditions world-wide and is associated with substantial pain and disability . Many people with knee OA also experience co-morbidities that further add to the OA burden . Uptake of and adherence to physical activity recommendations is suboptimal in this patient population , leading to poorer OA outcomes and greater impact of associated co-morbidities . This pragmatic r and omised controlled trial will investigate the clinical - and cost-effectiveness of adding telephone coaching to a physiotherapist-delivered physical activity intervention for people with knee OA . Methods / Design 168 people with clinical ly diagnosed knee OA will be recruited from the community in metropolitan and regional areas and r and omly allocated to physiotherapy only , or physiotherapy plus nurse-delivered telephone coaching . Physiotherapy involves five treatment sessions over 6 months , incorporating a home exercise program of 4–6 exercises ( targeting knee extensor and hip abductor strength ) and advice to increase daily physical activity . Telephone coaching comprises 6–12 telephone calls over 6 months by health practitioners trained in applying the Health Change Australia ( HCA ) Model of Health Change to provide behaviour change support . The telephone coaching intervention aims to maximise adherence to the physiotherapy program , as well as facilitate increased levels of participation in general physical activity . The primary outcomes are pain measured by an 11-point numeric rating scale and self-reported physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale after 6 months . Secondary outcomes include physical activity levels , quality -of-life , and potential moderators and mediators of outcomes including self-efficacy , pain coping and depression . Relative cost-effectiveness will be determined from health service usage and outcome data . Follow-up assessment s will also occur at 12 and 18 months . Discussion The findings will help determine whether the addition of telephone coaching sessions can improve sustainability of outcomes from a physiotherapist-delivered physical activity intervention in people with knee OA.Trial Registration Australian New Zeal and Clinical Trials Registry reference : Chronic musculoskeletal pain constitutes a large socioeconomic challenge , and preventive measures with documented effects are warranted . The authors ' aim in this study was to prospect ively investigate the association between physical exercise , body mass index ( BMI ) , and risk of chronic pain in the low back and neck/shoulders . The study comprised data on approximately 30,000 women and men in the Nord-Trøndelag Health Study ( Norway ) who reported no pain or physical impairment at baseline in 1984 - 1986 . Occurrence of  chronic musculoskeletal pain  was assessed at follow-up in 1995 - 1997 . A generalized linear model was used to calculate adjusted risk ratios . For both females and males , hours of physical exercise per week were linearly and inversely associated with risk of chronic pain in the low back ( women : P-trend = 0.02 ; men : P-trend < 0.001 ) and neck/shoulders ( women : P-trend = 0.002 ; men : P-trend < 0.001 ) . Obese women and men had an approximately 20 % increased risk of chronic pain in both the low back and the neck/shoulders . Exercising for 1 or more hours per week compensated , to some extent , for the adverse effect of high BMI on risk of chronic pain . The authors conclude that physical inactivity and high BMI are associated with an increased risk of chronic pain in the low back and neck/shoulders in the general adult population Abstract Purpose : Important goals of cardiac rehabilitation maintenance programs ( CMP ) are to increase leisure time physical activity ( LTPA ) and improve health-related quality of life ( HRQoL ) . Elderly patients with cardiac disease and low exercise capacity are simultaneously the most severely affected and have the most to gain from exercise-based rehabilitation . Individualized combined exercise ( ICE ) may be an effective modality to achieve these goals . We compared six months of ICE to CMP in their effects on LTPA and HRQoL. Methods : Sixty patients ( 70 ± 9 years , 39 % female ) with cardiac disease and low exercise capacity ( < 6 MET ) were r and omly allocated to six months of once-weekly ICE or CMP . The patients in ICE performed moderate endurance and resistance exercise on machines , based on intensities from individual peak exercise testing . Patients in CMP performed weekly sessions of calisthenics , flexibility , coordination and relaxation activities . LTPA and HRQoL were assessed with accelerometry and question naires at baseline and six months . Results : Sixty patients completed the trial . ICE  increased vigorous PA ( ICE : Δ + 12 MET-min/d , CMP : Δ –5 MET-min/d , p = .02 ) and steps per day ( ICE : + 1586 steps/d , CMP : –838 steps/d , p < .01 ) compared to CMP after six months . ICE significantly improved in several components of HRQoL ( vitality , emotional health , social health , positive and negative affect ( all p < .05 ) compared to CMP . Conclusions : ICE result ed in significant improvements in physical activity levels and health related quality of life in moderate to high-risk patients compared to CMP . Implication s for rehabilitation Relatively low volumes and intensities of exercise may lead to substantial improvements in both physical activity levels and health-related quality of life Exercise modes in cardiac rehabilitation maintenance programs should not be limited to calisthenics and large group-based exercise Supplemental resistance exercise may improve health-related quality of life and increase physical activity levels in patients with low exercise capacity Moderate to high-risk elderly patients also benefit from individualized endurance-resistance Background The prevalence and consequences of musculoskeletal pain is considerable among healthcare workers , allegedly due to high physical work dem and s of healthcare work . Previous investigations have shown promising results of physical exercise for relieving pain among different occupational groups , but the question remains whether such physical exercise should be performed at the workplace or conducted as home-based exercise . Performing physical exercise at the workplace together with colleagues may be more motivating for some employees and thus increase adherence . On the other h and , physical exercise performed during working hours at the workplace may be costly for the employers in terms of time spend . Thus , it seems relevant to compare the efficacy of workplace- versus home-based training on musculoskeletal pain . This study is intended to investigate the effect of workplace-based versus home-based physical exercise on musculoskeletal pain among healthcare workers . Methods / Design This study was design ed as a cluster r and omized controlled trial performed at 3 hospitals in Copenhagen , Denmark . Clusters are hospital departments and hospital units . Cluster r and omization was chosen to increase adherence and avoid contamination between interventions . Two hundred healthcare workers from 18 departments located at three different hospitals is allocated to 10 weeks of 1 ) workplace based physical exercise performed during working hours ( using kettlebells , elastic b and s and exercise balls ) for 5 × 10 minutes per week and up to 5 group-based coaching sessions , or 2 ) home based physical exercise performed during leisure time ( using elastic b and s and body weight exercises ) for 5 × 10 minutes per week . Both intervention groups will also receive ergonomic instructions on patient h and ling and use of lifting aides etc . Inclusion criteria are female healthcare workers working at a hospital . Average pain intensity ( VAS scale 0 - 10 ) of the back , neck and shoulder ( primary outcome ) and physical exertion during work , social capital and work ability ( secondary outcomes ) is assessed at baseline and 10-week follow-up . Further , postural balance and mechanical muscle function is assessed during clinical examination at baseline and follow-up . Discussion This cluster r and omized trial will investigate the change in self-rated average pain intensity in the back , neck and shoulder after either 10 weeks of physical exercise at the workplace or at home . Trial registration Clinical Trials.gov ( NCT01921764 ) Background Knee osteoarthritis ( OA ) is a prevalent chronic musculoskeletal condition with no cure . Pain is the primary symptom and results from a complex interaction between structural changes , physical impairments and psychological factors . Much evidence supports the use of strengthening exercises to improve pain and physical function in this patient population . There is also a growing body of research examining the effects of psychologist-delivered pain coping skills training ( PCST ) particularly in other chronic pain conditions . Though typically provided separately , there are symptom , re source and personnel advantages of exercise and PCST being delivered together by a single healthcare professional . Physiotherapists are a logical choice to be trained to deliver a PCST intervention as they already have expertise in administering exercise for knee OA and are cognisant of the need for a biopsychosocial approach to management . No studies to date have examined the effects of an integrated exercise and PCST program delivered solely by physiotherapists in this population . The primary aim of this multisite r and omised controlled trial is to investigate whether an integrated 12-week PCST and exercise treatment program delivered by physiotherapists is more efficacious than either program alone in treating pain and physical function in individuals with knee OA . Methods / design This will be an assessor-blinded , 3-arm r and omised controlled trial of a 12-week intervention involving 10 physiotherapy visits together with home practice . Participants with symptomatic and radiographic knee OA will be recruited from the community in two cities in Australia and r and omized into one of three groups : exercise alone , PCST alone , or integrated PCST and exercise .  R and omisation will be stratified by city ( Melbourne or Brisbane ) and gender . Primary outcomes are overall average pain in the past week measured by a Visual Analogue Scale and physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale . Secondary outcomes include global rating of change , muscle strength , functional performance , physical activity levels , health related quality of life and psychological factors . Measurements will be taken at baseline and immediately following the intervention ( 12 weeks ) as well as at 32 weeks and 52 weeks to examine maintenance of any intervention effects . Specific assessment of adherence to the treatment program will also be made at weeks 22 and 42 . Relative cost-effectiveness will be determined from health service usage and outcome data . Discussion The findings from this r and omised controlled trial will provide evidence for the efficacy of an integrated PCST and exercise program delivered by physiotherapists in the management of painful and functionally limiting knee OA compared to either program alone . Trial registration Australian New Zeal and Clinical Trials Registry reference number : Background It is well recognised that low back pain is a significant public health problem and engagement in moderate levels of physical activity is associated with positive outcomes .Conservative active care , such as exercise , is effective in reducing pain and disability associated with chronic low back pain . However , a rapid decline in clinical outcomes is commonly seen after discharge from treatment . Methods / Design We will conduct a r and omised controlled trial to investigate the effectiveness of a mobile health supported physical activity intervention ( compared to st and ard care ) in care-seeking , pain and disability in people with chronic low back pain after discharge from treatment . We will recruit 68 patients with chronic low back pain following discharge from an outpatient hospital program , who will be r and omly allocated to the physical activity intervention ( n = 34 ) or the st and ard care group ( n = 34 ) and monitored for 6 months . The physical activity intervention will involve a physical activity advice booklet , a face-to-face health coaching session and 12 fortnightly follow-up telephone-based health coaching sessions . This intervention will be supported by provision of a specifically design ed web app and a physical activity monitoring device ( FitBit ) . The st and ard care group will receive the physical activity advice booklet only . Discussion This pilot trial will investigate a new model to prevent clinical decline in people following conservative treatment for chronic low back pain . If proven to be effective , this approach will constitute a major advance in the management of low back pain . Chronic patients who experience recurrent pain and disability after treatment are prone to seek additional care in the form of physiotherapy , medication , emergency department attendance , specialist consultation or spinal surgery . This model aims to maintain functional levels and reduce care-seeking empowering patients to self-manage their low back pain by offering them a contemporary patient-centred physical activity program with the support of mobile health technology . The outcomes of this trial will have immediate implication s for clinical practice .Trial registration ACTRN12615000189527 ( 26 - 02 - 2015 ) BACKGROUND Chronic musculoskeletal pain is prevalent among laboratory technicians and work-related stress may aggravate the problem . OBJECTIVES This study investigated the effect of a multifaceted worksite intervention on pain and stress among laboratory technicians with chronic musculoskeletal pain using individually tailored physical and cognitive elements . STUDY DESIGN This trial uses a single-blind r and omized controlled design with allocation concealment in a 2-armed parallel group format among laboratory technicians . The trial " Implementation of physical exercise at the Workplace (IRMA09)--Laboratory technicians " was registered at Clinical Trials.gov prior to participant enrolment . SETTING The study was conducted at the head division of a large private pharmaceutical company 's research and development department in Denmark . The study duration was March 2014 ( baseline ) to July 2014 ( follow-up ) . METHODS Participants ( n = 112 ) were allocated to receive either physical , cognitive , and mindfulness group-based training ( PCMT group ) or a reference group ( REF ) for 10 weeks at the worksite . PCMT consisted of 4 major elements : 1 ) resistance training individually tailored to the pain affected area , 2 ) motor control training , 3 ) mindfulness , and 4 ) cognitive and behavioral therapy/education . Participants of the REF group were encouraged to follow ongoing company health initiatives . The predefined primary outcome measure was pain intensity ( VAS scale 0 - 10 ) in average of the regions : neck , shoulder , lower and upper back , elbow , and h and at 10 week follow-up . The secondary outcome measure was stress assessed by Cohen´s perceived stress question naire . In addition , an explorative dose-response analysis was performed on the adherence to PCMT with pain and stress , respectively , as outcome measures . RESULTS A significant ( P < 0.0001 ) treatment by time interaction in pain intensity was observed with a between-group difference at follow-up of -1.0 ( 95%CI : -1.4 to -0.6 ) . No significant effect on stress was observed ( treatment by time P = 0.16 ) . Exploratory analyses for each body region separately showed significant pain reductions of the neck , shoulders , upper back and lower back , as well as a tendency for h and pain . Within the PCMT group , general linear models adjusted for age , baseline pain , and stress levels showed significant associations for the change in pain with the number of physical-cognitive training sessions per week ( -0.60 [ 95%CI -0.95 to -0.25 ] ) and the number of mindfulness sessions ( 0.15 [ 95%CI 0.02 to 0.18 ] ) . No such associations were found with the change in stress as outcome . LIMITATIONS Limitations of behavioral interventions include the inability to blind participants to which intervention they receive . Self-reported outcomes are a limitation as they may be influenced by placebo effects and outcome expectations . CONCLUSIONS We observed significant reductions in chronic musculoskeletal pain following a 10-week individually adjusted multifaceted intervention with physical training emphasizing dynamic joint mobility and mindfulness coupled with fear-avoidance and de-catastrophizing behavioral therapy compared to a reference group encouraged to follow on-going company health initiatives . A higher dose of physical-cognitive training appears to facilitate pain reduction , whereas a higher dose of mindfulness appears to increase pain . Hence , combining physical training with mindfulness may not be an optimal strategy for pain reduction . TRIAL REGISTRATION NCT02047669 Abstract Objective To assess the cost effectiveness of adding spinal manipulation , exercise classes , or manipulation followed by exercise ( “ combined treatment ” ) to “ best care ” in general practice for patients consulting with low back pain . Design Stochastic cost utility analysis alongside pragmatic r and omised trial with factorial design . Setting 181 general practice s and 63 community setting s for physical treatments around 14 centres across the United Kingdom . Participants 1287 ( 96 % ) of 1334 trial participants . Main outcome measures Healthcare costs , quality adjusted life years ( QALYs ) , and cost per QALY over 12 months . Results Over one year , mean treatment costs relative to “ best care ” were £ 195 ( $ 360 ; € 279 ; 95 % credibility interval £ 85 to £ 308 ) for manipulation , £ 140 ( £ 3 to £ 278 ) for exercise , and £ 125 ( £ 21 to £ 228 ) for combined treatment . All three active treatments increased participants ' average QALYs compared with best care alone . Each extra QALY that combined treatment yielded relative to best care cost £ 3800 ; in economic terms it had an “ incremental cost effectiveness ratio ” of £ 3800 . Manipulation alone had a ratio of £ 8700 relative to combined treatment . If the NHS was prepared to pay at least £ 10 000 for each extra QALY ( lower than previous recommendations in the United Kingdom ) , manipulation alone would probably be the best strategy . If manipulation was not available , exercise would have an incremental cost effectiveness ratio of £ 8300 relative to best care . Conclusions Spinal manipulation is a cost effective addition to “ best care ” for back pain in general practice . Manipulation alone probably gives better value for money than manipulation followed by exercise Osteoarthritis is the leading cause of persistent knee pain , affecting around one quarter of adults ( 1 , 2 ) , and is a major contributor to global disability ( 3 ) . Knee osteoarthritis causes loss of function , reduced quality of life , and psychological disability ( 4 ) . It has no cure and , given the aging population and increasing obesity rates , disease burden is rapidly increasing ( 5 , 6 ) . The urgent need for effective and accessible models of health service delivery that can be provided on a population level has been recognized as a research priority by key stakeholders ( 7 ) . Such models should take a biopsychosocial approach ; emphasize nondrug , nonsurgical treatment ; and foster self-management , of which appropriate educational information is a core component ( 8) . Exercise has well-established benefits for pain and function in persons with knee osteoarthritis ( 911 ) and is recommended by clinical guidelines as the cornerstone of conservative management ( 12 ) . It is often prescribed by a health professional and can be performed effectively at home ( 9 ) . Evidence also supports  pain-coping skills training ( PCST ) , an approach based on cognitive behavioral principles , to target psychological factors , such as low self-efficacy , poor pain coping , and pain catastrophizing , that are common in persons with chronic pain ( 13 , 14 ) . However , for many , accessing specialist clinicians to prescribe and supervise these treatments may be difficult due to cost , transport issues , or geographic location , particularly in regional and rural areas where services may be limited or nonexistent ( 15 , 16 ) . The Internet is a time-efficient and convenient method to deliver health interventions with broad reach ( 17 , 18 ) . Educational material is often accessed online by persons with chronic pain ( 19 ) . Remotely delivered physiotherapy and exercise can benefit persons with knee pain and osteoarthritis ( 2022 ) and those who have undergone knee joint replacement , albeit often using sophisticated technology ( 23 ) . An Internet-based interactive PCST program ( PainCOACH ) , design ed to translate key therapeutic elements of clinician-delivered face-to-face PCST ( 24 ) , showed improved outcomes in persons with hip or knee osteoarthritis ( 25 ) . An online intervention combining these treatments aligns with a biopsychosocial approach to chronic disease management ( 8) but has not been investigated in this patient population . This study aim ed to evaluate the effectiveness of an innovative Internet-based intervention combining physiotherapist-prescribed home exercise delivered via videoconferencing ( Skype [ Microsoft ] ) and automated PCST in addition to educational material in persons with chronic knee pain . Our primary hypothesis was that the intervention would reduce pain and improve physical function after 3 months compared with educational material only . Supplement . Study Protocol Methods Design Overview We conducted a parallel , 2-group pragmatic r and omized , controlled trial . The protocol has been published ( 26 ) . The trial was prospect ively registered with the Australian New Zeal and Clinical Trials Registry ( ACTRN12614000243617 ) . Initial registration erroneously listed the Depression , Anxiety and Stress Scale ( DASS-21 ) as a secondary outcome rather than an eligibility screening tool . We amended the registry after enrolling 16 participants but before collecting follow-up data . No interim analyses were performed . The Institutional Human Ethics Committee approved the trial , and participants provided informed consent . Recruitment occurred from March 2014 to May 2015 , with follow-up completed in February 2016 . Participants and physiotherapists were unblinded to group allocation and were aware of the alternative treatment components , but study hypotheses were not disclosed to participants . The statistician was blinded . A nested health economic evaluation and a qualitative study exploring patients ' and physiotherapists ' experiences will be published separately . Setting and Participants We recruited community-dwelling participants from Australia via print , radio , and social media advertisements and our data base .  Eligibility was confirmed using an online survey followed by a telephone interview .  Inclusion criteria were age 50 years or older , knee pain for more than 3 months and on most days of the previous month , knee pain during walking ( score of 4 on an 11-point numerical rating scale [ NRS ] , with terminal descriptors of no pain and worst pain possible ) in the previous week , mild to moderate physical dysfunction ( score > 20 out of 68 on the physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index [ WOMAC ] ) , and an active e-mail account and a computer with Internet access . Exclusion criteria were joint replacement in the symptomatic knee , awaiting joint replacement surgery , intra-articular corticosteroid injection or knee surgery in the previous 6 months or planned joint surgery in the subsequent 9 months , treatment for knee pain or participation in a strengthening exercise or PCST program in the previous 6 months , systemic arthritic condition , neurologic condition affecting the lower limb or limiting exercise , pain at another site that was worse than knee pain or limited exercise , and high-level depression ( score > 21 on the depression subscale of the DASS-21 [ 27 ] ) . R and omization and Interventions Computer-generated r and omization was conducted by r and om permuted blocks of size 2 to 8 stratified by sex and residence ( metropolitan or regional/rural ) . The r and omization schedule was prepared by an independent biostatistician and concealed from the research er enrolling participants in sequentially numbered , opaque , sealed envelopes . Intervention Participants received 3 Internet-delivered treatments . The first was educational material about exercise and physical activity , pain management , emotions , healthy eating , complementary therapies , and medications ( www.arthritisaustralia.com.au ) . Participants were encouraged to access the material at their leisure . The second was an interactive automated PCST program ( PainCOACH ) ( 24 , 25 ) . Participants were asked to complete eight 35- to 45-minute modules ( 1 per week commencing in week 1 ) and practice pain-coping skills daily ( Appendix Table 1 ) . These skills included progressive relaxation , activityrest cycling , scheduling pleasant activities , changing negative thoughts , pleasant imagery and distraction techniques , and problem solving . The third was 7 Skype sessions with a physiotherapist over 12 weeks ( in weeks 2 , 3 , 4 , 6 , 8 , 10 , and 12 ) . Sessions lasted 45 minutes in weeks 2 and 12 and 30 minutes in the other weeks . Physiotherapists were allocated to participants on the basis of availability , and the same physiotherapist undertook all consultations with any given participant . The physiotherapist performed a brief assessment and prescribed a lower-limbstrengthening home exercise program to be performed 3 times per week ( 26 , 28 ) ( Appendix Table 2 ) . Exercise progression was provided by varying the exercises , repetitions , load , or difficulty to approximate a 10-repetition maximum level and a self-rated effort level of at least 5 out of 10 ( hard ) on a modified Borg Rating of Perceived Exertion scale ( 29 ) . Participants were provided with instructions , video demonstrations , and equipment ( such as resistance b and s and ankle weights ) . They also were encouraged to increase physical activity levels , received written information about how to do so , and were given the option of using a pedometer for motivation ( provided at no cost ) . Appendix Table 1 . Summary of the Internet-Based PainCOACH Content * Appendix Table 2 . Home Exercise Program Protocol * Generic e-mail reminders to complete PainCOACH modules were sent weekly during the first 8 weeks . At week 11 and at monthly intervals from week 13 , participants received e-mails encouraging them to review the final module , revisit useful or meaningful modules , and continue home exercise and pain-coping skills practice .  Eight physiotherapists ( 4 men ) with an average of 16 years ( range , 3 to 28 years ) of clinical musculoskeletal experience were trained to deliver the exercise component . Physiotherapists attended a 1-day training course conducted by the research ers and were given an exercise manual . They also were provided with an overview of PainCOACH and were asked to encourage participants to complete modules and practice skills . Regular telephone and Skype meetings between the physiotherapists and the research ers were held to discuss implementation of the intervention . A brief video showing a mock physiotherapy session is provided in the Supplement Video . Control The control group received access to the same online educational material as the intervention group . Outcomes and Follow-up Participants completed measurements online at baseline , 3 months ( primary time point ) , and 9 months . They received a $ 50AUD gift voucher for completing all question naires . The primary outcomes were valid and reliable self-reported measures of pain and physical function that are recommended for knee osteoarthritis clinical trials ( 30 ) . Overall average pain during walking over the previous week was measured with an NRS , with terminal descriptors of no pain ( score of 0 ) and worst pain possible ( score of 10 ) and a minimum clinical ly important difference ( MCID ) of 1.8 units ( 31 ) . Difficulty with physical function over the previous 48 hours was measured with the WOMAC ( Likert version 3.1 ) physical function subscale ( 32 ) , with total scores ranging from 0 ( no dysfunction ) to 68 ( maximum dysfunction ) and an MCID of 6 units ( 33 ) . Secondary outcomes included knee pain over the previous 48 hours , measured using the WOMAC pain subscale ( 32 ) ( scores range from 0 [ no pain ] to 20 [ maximum pain ] ) ; global change overall , in pain , and in physical function , measured using 7-point Likert scales with terminal descriptors of much worse to much better ( measured at 3 and 9 months ) ; health-related quality of life , BACKGROUND Although guidelines for the management of low back pain have been published in the past decade , there is potential for further improvement in back pain care . AIM To document the management of non-specific low back pain by general practitioners ( GPs ) in the Netherl and s , to determine how this management of care is related to patient and physician factors , and to explore possible reasons for not adhering to the guidelines . METHOD A prospect i ve study was set up in which 57 GPs in 30 general practice s completed a computerised question naire after each consultation for low back pain during a four-month period . RESULTS Of 1640 back pain contacts , 1180 referred to non-specific low back pain . Diagnostic tests were ordered in 2 % of first consultations and in 7 % of follow-up consultations within one episode . The advice to  stay active  despite  pain  was given in 76 % and 69 % of these cases respectively . Patients were prescribed an  analgesic  in 53 % and 41 % of cases respectively ( mainly NSAIDs [ 80 % ] ) . Patients were referred to a physiotherapist in 22 % of first and in 50 % of follow-up consultations . Older patients were physically examined less often , prescribed analgesics more often , and were told less often that staying active could benefit them . The advice to remain active was omitted more often when symptoms lasted longer . Only a small part of the variance in management was accounted for by patient characteristics or by differences between practice s. CONCLUSION The management of low back pain met the guidelines to a large extent . Management decisions were often related to characteristics in which the guidelines lack differentiation . Important reasons for non-adherence were perceived patients ' preferences . Further implementation of guidelines will be difficult unless doctors ' and patients ' views are more explicitly known Background Evidence suggests that to facilitate physical activity sedentary people may adhere to one component of exercise prescriptions ( intensity , duration or frequency ) without adhering to other components . Some experts have provided evidence for determinants of adherence to different components among healthy people . However , our underst and ing remains scarce in this area for patients with neck or low back pain . The aims of this study are to determine whether patients with neck or low back pain have different rates of adherence to exercise components of frequency per week and duration per session when prescribed with a home exercise program , and to identify if adherence to both exercise components have distinct predictive factors . Methods A cohort of one hundred eighty-four patients with chronic neck or low back pain who attended physiotherapy in eight primary care centers were studied prospect ively one month after intervention . The study had three measurement periods : at baseline ( measuring characteristics of patients and pain ) , at the end of physiotherapy intervention ( measuring characteristics of the home exercise program ) and a month later ( measuring professional behaviors during clinical encounters , environmental factors and self-efficacy , and adherence behavior ) . Results Adherence to duration per session ( 70.9 % ± 7.1 ) was more probable than adherence to frequency per week ( 60.7 % ± 7.0 ) . Self-efficacy was a relevant factor for both exercise components ( p < 0.05 ) . The total number of exercises prescribed was predictive of frequency adherence ( p < 0.05 ) . Professional behaviors have a distinct influence on exercise components . Frequency adherence is more probable if patients received clarification of their doubts ( adjusted OR : 4.1 ; p < 0.05 ) , and duration adherence is more probable if they are supervised during the learning of exercises ( adjusted OR : 3.3 ; p < 0.05 ) . Conclusion We have shown in a clinic-based study that adherence to exercise prescription frequency and duration components have distinct levels and predictive factors . We recommend additional study , and advise that differential attention be given in clinical practice to each exercise component for improving adherence The aim of the present study was to compare the effect of increased aerobic capacity versus muscle strength rehabilitation of female hospital staff with long-lasting musculoskeletal back pain . Seventy-nine women agreed to participate in the intervention study . After a medical examination , 65 individuals were assigned to one of three balanced groups : Endurance training ( aerobic capacity promoting training : ET : n = 22 ) , strength promotion exercise ( SP : n = 24 ) or a control group ( CON : n = 19 ) . The active groups met twice a week for 60 minutes of exercise over 15 weeks . Aerobic capacity ( VO2max ) and musculoskeletal pain were measured immediately before ( T1 ) and after the intervention period ( T2 ) . Aerobic capacity significantly increased in the ET group , whereas no change was observed in the SP group , and a significant reduction was found in the CON group from T1 to T2 . Musculoskeletal pain was significantly reduced in both intervention groups , whereas minor changes were observed in the control group . Results from a 7-month follow-up ( T3 ) survey confirmed the beneficial effects of interventions on musculoskeletal pain . In conclusion , improved aerobic capacity appeared not to be a necessary mechanism in musculoskeletal back pain reduction Context Low back pain causes frequent disability and lost productive time . Contribution This r and omized trial compared a behavioral-oriented grade d activity program with usual care in 134 Dutch airline company workers who had missed work because of persistent low back pain .  Grade d activity consisted of biweekly 1-hour exercise sessions with physiotherapists who emphasized operant-conditioning principles . Over 6 months of follow-up , participants in the grade d activity program missed 58 days of work , while participants receiving usual care missed 87 days . Implication s A behavioral-oriented grade d activity program returned participants with low back pain to work more often than did usual care . The Editors Nonspecific low back pain is an uncomfortable medical condition that causes frequent disability and absence from work . Most episodes of low back pain resolve fairly quickly and cause only short periods of absence from work . However , some workers with low back pain miss work for several days to weeks and are at risk for more permanent disability ( 1 ) . To reduce the individual and socioeconomic burden related to this absenteeism , we need effective intervention strategies in occupational health care setting s that promote safe and rapid return to work . One promising and often-advocated intervention strategy for workers with prolonged nonspecific low back pain is active rehabilitation that is directed toward return to normal activity and work ( 2 ) . Examples are grade d activity interventions that include physical exercise , application of operant-conditioning behavioral principals , and promotion of improved functioning and safe return to work even if pain persists ( 3 - 6 ) . In a r and omized , controlled trial , Lindstrm and colleagues ( 3 , 4 ) found that a grade d activity intervention reduced absence from work more than did traditional care in Swedish workers employed in the automobile industry . We investigate , in a second r and omized , controlled trial , whether absence from work because of low back pain is reduced more with grade d activity intervention than with traditional care in an occupational health care setting in the Netherl and s. Methods Study Design and Sample The study was a single-blind , r and omized , controlled trial in an occupational health services center ( KLM Health , Safety and Environment ) at Schiphol Airport , Amsterdam , the Netherl and s. The center provides occupational health services for all employees of a major Dutch airline ( KLM Royal Dutch Airlines ) . The source sample ( n = 20 000 ) consisted of workers who were employed in the following organizational units of the airline : baggage and aircraft turnaround services , passenger services , engineering and maintenance , cargo , and cabin and cockpit . Workers who were listed as absent from work because of low back pain were invited for a consultation with the occupational physician . Those who were thought to be eligible for inclusion were referred to the research assistant , who judged whether they met the inclusion criteria : full or partial absence from work because of nonspecific low back pain and low back pain symptoms with a minimum duration of 4 weeks in succession . The exclusion criteria were low back pain with radiation below the knee with signs of nerve-root compression ( 7 ) ; cardiovascular contraindications for physical activity , as checked according to the Physical Activities Readiness Question naire ( 8 , 9 ) ; any conflict between worker and employer with legal involvement ; or pregnancy . Workers who met the inclusion criteria were informed of the purpose and procedures of the study and were enrolled after giving informed consent . The Medical Ethical Committee of the VU University Medical Center , Amsterdam , the Netherl and s , approved the study . Treatment Allocation The participants were assigned to grade d activity or usual care on the basis of block r and omization , after prestratification for the organizational unit in the workplace from which they were recruited ( the 5 organizational units listed earlier ) and for the severity of pain symptoms ( scored on a scale of 0 to 10 ; severity scores were < 6 or 6 points ) . This result ed in a total of 10 strata . R and omized , permuted blocks of 4 allocations were generated for each stratum through a computer-generated r and om-sequence table . Opaque , sequentially numbered , sealed envelopes were prepared for each stratum by a research er who was not involved in enrolling the participants or assigning them to their groups . The envelopes contained a sheet of paper that indicated 1 of the 2 interventions . Participants learned their group assignments after a research assistant completed the baseline measurements and delivered the sealed envelopes . Blinding The research assistants who collected the data were blinded to the treatment allocation . All participants were repeatedly asked not to reveal any information about their treatment allocation . The participants and treatment providers were not blinded to treatment allocation . Interventions In the Dutch occupational health care system , occupational physicians guide disabled workers who are absent from work through their disability period . These occupational physicians are employed by occupational health services that are paid for by the companies . The occupational physicians adhere to back pain management strategies that consist of advising workers on ergonomics , prevention , and return-to-work schedules and advising and communicating with other stakeholders ( such as health care providers and representatives of the workplace ) . Disabled workers who participated in the present study were assigned to either grade d activity or usual care within the context of the Dutch occupational health care setting . Grade d Activity The intervention group received the usual guidance from the occupational physician about work-related problems and barriers to return to work as well as the grade d activity intervention supervised by a physiotherapist .  Three physiotherapists who worked in a private practice at Schiphol Airport provided the treatment according to the grade d activity protocol . Two of those physiotherapists were also trained as manual therapists , and 1 was also a human movement scientist . Before the study , the physiotherapists had been specifically trained to treat patients with low back pain according to behavioral principles . A research physiotherapist who was experienced in treating patients with chronic pain in rehabilitation centers instructed the physiotherapists in three 2-hour sessions and practice d patienttherapist interactions with them through role-play . Before the study , the physiotherapists treated several patients according to the grade d activity protocol to gain more experience . The physiotherapists made audiotapes of the intervention sessions before and during the study period . The contents of these audiotapes were assessed and discussed with the research physiotherapist in 3 additional meetings . Furthermore , the physiotherapists summarized the treatment after each session , and research ers used these summaries to review the sessions . The same physiotherapist treated participants each time , except for temporary st and -in sessions that were supervised by colleagues because of holidays or other reasons . Specific therapists were not systematic ally selected to treat specific participants ; selection was based on pragmatic reasons , such as the time available in the work schedules of the physiotherapists or the days of treatment preferred by the participants . Table 1 presents the concept and content of the grade d activity intervention . The intervention consisted of 1-hour exercise sessions that participants attended twice per week until they returned completely to regular work or until the maximum therapy duration of 3 months was reached . At the start of the intervention , the physiotherapist inquired about the participant 's medical history and completed a brief physical examination consisting of flexion , extension , and lateroflexion of the lumbar spine and a brief screening for nerve-root pain ( 10 ) . The purpose of the physical examination was to confirm the diagnosis of benign , nonspecific low back pain and to reduce participants ' fears about any presumed underlying disease . The participants were reassured that despite the annoying pain , nothing was seriously wrong with their backs . Subsequently , the physiotherapist and participant decided on a set of general exercises and individually tailored exercises . Both types of exercises had to be performed during each session . The general exercises were aerobic exercises , such as cycling or rowing , and strengthening exercises for large muscle groups , and most were carried out in a gym while using exercise equipment . The strengthening exercises were a floor abdominal sit-up exercise , a dynamic back extension exercise , a leg-press exercise , a latissimus pull-down exercise , and st and ing up from a low chair .  Participants in the grade d activity group had to perform not only these general exercises but also individually tailored exercises , which imitated physical tasks at work or difficult and painful activities of daily living . For example , a participant who reported back problems while lifting and moving suitcases from a luggage wagon into an airplane might be given an exercise to practice lifting and moving a suitcase with a certain number of repetitions . During the first 3 sessions , the maximal performance ( for example , the maximum number of repetitions ) was assessed for each exercise separately , and the average score for each exercise over the 3 sessions was used as a baseline value for specifying a gradually progressive exercise scheme . Subsequently , the participant was asked to propose a date for full return to regular work , which would consequently be the end point of the physical exercise program . Before returning to full regular work , participants could return to work with modified hours and duties . Advised by the physiotherapist , the participant Purpose To assess effects of 1-year Intelligent Physical Exercise Training ( IPET ) on  musculoskeletal health . Methods Office workers were r and omized 1 : 1 to a training group , TG ( N = 193 ) , or a control group , CG ( N = 194 ) . TG received 1 h supervised high intensity IPET every week within working hours for 1 year and was recommended to perform 30 min of moderate intensity physical activity for 6 days a week during leisure . The IPET program was based on baseline health measures . Results No baseline differences were present . An intention-to-treat analysis showed significant between-group effect for muscle strength but not for musculoskeletal pain . However , a per- protocol analysis of those with an adherence of ≥70 % demonstrated a significant between-group effect for neck pain during the past three months . Several significant within-group changes were present , where TG and TG ≥ 70 % demonstrated clinical ly relevant pain reductions whereas minimal reductions were seen for CG . Conclusion IPET and recommendations of moderate intensity physical activity demonstrated significant between-group effect on muscle strength . Interestingly , significant within-group reductions in musculoskeletal pain were seen not only in TG but also in CG . This may underlie the lack of such between-group effect and shows that a possible positive side effect of merely drawing attention can improve musculoskeletal health OBJECTIVE To determine the point prevalence of chronic musculoskeletal ankle disorders in the community . DESIGN Cross-sectional stratified ( metropolitan vs regional ) r and om sample . SETTING General community . PARTICIPANTS  Population -based computer-aided telephone survey of people ( N=2078 ) aged 18 to 65 years in New South Wales , Australia . Of those contacted , 751 participants provided data . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Point prevalence for no history of ankle injury or chronic ankle problems ( no ankle problems ) , history of ankle injury without residual problems , and chronic ankle disorders . Chronic musculoskeletal ankle disorders due to ankle sprain , fracture , arthritis , or other disorder compared by chi-square test for the presence of pain , weakness , giving way , swelling and instability , activity limitation , and health care use in the past year . RESULTS There were 231 ( 30.8 % ) participants with no ankle problems , 342 ( 45.5 % ) with a history of ankle injury but no chronic problems , and 178 ( 23.7 % ) with chronic ankle disorders . The major component of chronic ankle disorders was musculoskeletal disorders ( n=147 , 19.6 % of the total sample ) , most of which were due to ankle injury ( n=117 , 15.6 % of the total ) . There was no difference among the arthritis , fracture , sprain , and other groups in the prevalence of the specific complaints , or health care use . Significantly more participants with arthritis had to limit activity than in the sprain group ( Chi-square test , P=.035 ) . CONCLUSIONS Chronic musculoskeletal ankle disorders affected almost 20 % of the Australian community . The majority were due to a previous ankle injury , and most people had to limit or change their physical activity because of the ankle disorder Background : Prevalence of musculoskeletal pain is high in jobs with high physical work dem and s. An aerobic exercise intervention targeting cardiovascular health was evaluated for its long term side effects on musculoskeletal pain . Objective : The objective was to investigate if aerobic exercise affects level of musculoskeletal pain from baseline to 4- and 12-months follow-up . Methods : One-hundred- and -sixteen cleaners aged 18–65 years were cluster-r and omized . The aerobic exercise group ( n = 57 ) received worksite aerobic exercise ( 30 min twice a week ) and the reference group ( n = 59 ) lectures in health promotion . Strata were formed according to closest manager ( total 11 strata ) ; clusters were set within strata ( total 40 clusters , 20 in each group ) . Musculoskeletal pain data from eight body regions was collected at baseline and after 4- and 12-months follow-up . The participants stated highest pain in the last month on a scale from 0 , stating no pain , up to 10 , stating worst possible pain . A repeated-measure 2 × 2 multi-adjusted mixed-models design was applied to compare the between-groups differences in an intention to treat analysis . Participants were entered as a r and om effect nested in clusters to account for the cluster-based r and omization . Results : Clinical ly significant reductions ( > 30 % , f 2 > 0.25 ) in the aerobic exercise group , compared to the reference group , in pain intensity in neck , shoulders , arms/wrists were found at 12-months follow-up , and a tendency ( p = 0.07 , f 2 = 0.18 ) to an increase for the knees . At 4-months follow-up the only significant between-group change was an increase in hip pain . Conclusions : This study indicates that aerobic exercise  reduces musculoskeletal pain in the upper extremities , but as an unintended side effect may increase pain in the lower extremities . Aerobic exercise interventions among workers st and ing or walking in the majority of the working hours should tailor exercise to only maintain the positive effect on musculoskeletal pain Background Active approaches including both specific and unspecific exercise are probably the most widely recommended treatment for patients with chronic low back pain but it is not known exactly which types of exercise provide the most benefit . Nordic Walking - power walking using ski poles - is a popular and fast growing type of exercise in Northern Europe that has been shown to improve cardiovascular metabolism . Until now , no studies have been performed to investigate whether Nordic Walking has beneficial effects in relation to back pain . Methods A total of 151 patients with low back and /or leg pain of greater than eight weeks duration were recruited from a hospital based outpatient back pain clinic . Patients continuing to have pain greater than three on the 11-point numeric rating scale after a multidisciplinary intervention were included . Fifteen patients were unable to complete the baseline evaluation and 136 patients were r and omized to receive A ) Nordic walking supervised by a specially trained instructor twice a week for eight weeks B ) One-hour instruction in Nordic walking by a specially trained instructor followed by advice to perform Nordic walking at home as much as they liked for eight weeks or C ) Individual oral information consisting of advice to remain active and about maintaining the daily function level that they had achieved during their stay at the backcenter . Primary outcome measures were pain and disability using the Low Back Pain Rating Scale , and functional limitation further assessed using the Patient Specific Function Scale . Furthermore , information on time off work , use of medication , and concurrent treatment for their low back pain was collected . Objective measurements of physical activity levels for the  supervised and unsupervised Nordic walking groups were performed using accelerometers . Data were analyzed on an intention-to-treat basis . Results No mean differences were found between the three groups in relation to any of the outcomes at baseline . For pain , disability , and patient specific function the supervised Nordic walking group generally faired best however no statistically significant differences were found . Regarding the secondary outcome measures , patients in the supervised group tended to use less pain medication , to seek less concurrent care for their back pain , at the eight-week follow-up . There was no difference between physical activity levels for the supervised and unsupervised Nordic walking groups . No negative side effects were reported . Conclusion We did not find statistically significant differences between eight weeks of supervised or unsupervised Nordic walking and advice to remain active in a group of chronic low back pain patients . Nevertheless , the greatest average improvement tended to favor the supervised Nordic walking group and - taking into account other health related benefits of Nordic walking - this form of exercise may potentially be of benefit to selected groups of chronic back pain patients .Trial registration http://www . Clinical Trials.gov # AIM This paper reports a study of the effects of aquatic exercise on physical fitness ( flexibility , strength and aerobic fitness ) , self-reported physical functioning and pain in adults with osteoarthritis of the hip or knee . BACKGROUND Osteoarthritis is a common cause of disability and a primary reason for hip and knee joint replacement . Exercise is important for preventing and /or managing the functional limitations associated with joint disease . Aquatic exercise is thought to be beneficial and is often recommended for people with osteoarthritis ; however , few studies have examined the effects on people with osteoarthritis , and these have yielded inconsistent results . METHODS A two-group r and omized controlled trial with a convenience sample was used . Participants were recruited from community sources and r and omly assigned to a 12-week aquatic programme or a non-exercise control condition . Data for 38 participants were collected at baseline , week 6 , and week 12 during 2003 and 2004 . Instruments were a st and ard plastic goniometer , a h and held dynamometer , the 6-minute walk test , the multidimensional Health Assessment Question naire , and a visual analogue scale for pain . RESULTS Repeated measures analysis of variance showed that aquatic exercise statistically significantly improved knee and hip flexibility , strength and aerobic fitness , but had no effect on self-reported physical functioning and pain . The exercise adherence rate was 81.7 % , and no exercise-related adverse effect was observed or reported . CONCLUSIONS Beneficial short-term effects of aquatic exercise were found in adults with osteoarthritis of the hip or knee . Although the programme may not offer pain relief or self-reported improvements in physical functioning , results suggest that aquatic exercise does not worsen the joint condition or result in injury . Nurses engaging in disease management and health promotion for these patients should consider recommending or implementing aquatic classes for patients IMPORTANCE Many site-specific , multivariable risk models for predicting the outcome of musculoskeletal pain problems have been published . The overlapping content in these models suggests a common set of generic indicators suitable for use in primary care . OBJECTIVE To investigate whether a brief set of generic prognostic indicators can predict the outcome of musculoskeletal pain in older patients presenting to general practitioners . DESIGN , SETTING , AND PARTICIPANTS A prospect i ve observational cohort study conducted from September 1 , 2006 , through March 31 , 2007 , of consecutive patients 50 years or older presenting with noninflammatory musculoskeletal pain to 1 of the 5 participating general practice s in the United Kingdom . MAIN OUTCOME MEASURES During consultation , the treating physician assessed and recorded 5 brief generic items ( duration of present pain episode , current pain intensity , pain interference with daily activities , presence of multiple-site pain , and ultrashort depression screen ) and recorded their overall prognostic judgment . The primary outcome was patient-rated improvement , which was measured 6 months after consultation and cross-vali date d with repeated measures up to 3 years . RESULTS A total of 194 ( 48.1 % ) of 403 participants were classified as having an unfavorable outcome at 6 months . Inclusion of 3 generic prognostic indicators ( duration of present pain episode , pain interference with daily activities , and presence of multiple-site pain ) in the prognostic model improved on reliance on physicians ' prognostic judgment alone ( C statistic = 0.72 vs 0.62 ; net reclassification index = 0.136 ; proportion correctly classified = 69 % ) . The improvement in prognostic accuracy was attributable to correcting physicians ' tendency toward overoptimistic expectations of outcome . CONCLUSIONS AND RELEVANCE Three easy-to-obtain pieces of information followed by systematic recording of the general practitioners ' prognostic judgment provide a simple generic assessment of prognosis at point of care in older persons presenting with musculoskeletal problems to primary care practice s in the United Kingdom . Such an assessment offers a common foundation for investigating the usefulness of prognostic stratification for guiding management in the consultation across a range of common painful conditions Study Design . Systematic Review . Objectives . To assess the effects of massage therapy for nonspecific low back pain . Summary of Background Data . Low back pain is one of the most common and costly musculoskeletal problems in modern society . Proponents of massage therapy cl aim it can minimize pain and disability , and speed return to normal function . Methods . We search ed MEDLINE , EMBASE , CINAHL from their beginning to May 2008 . We also search ed the Cochrane Central Register of Controlled Trials ( The Cochrane Library 2006 , issue 3 ) , HealthSTAR and Dissertation abstract s up to 2006 . There were no language restrictions . References in the included studies and in review s of the literature were screened . The studies had to be r and omized or quasi-r and omized trials investigating the use of any type of massage ( using the h and s or a mechanical device ) as a treatment for nonspecific low back pain . Two review authors selected the studies , assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group , and extracted the data using st and ardized forms . Both qualitative and meta-analyses were performed . Results . Thirteen r and omized trials were included . Eight had a high risk and 5 had a low risk of bias . One study was published in German and the rest in English . Massage was compared to an inert therapy ( sham treatment ) in 2 studies that showed that massage was superior for pain and function on both short- and long-term follow-ups . In 8 studies , massage was compared to other active treatments . They showed that massage was similar to exercises , and massage was superior to joint mobilization , relaxation therapy , physical therapy , acupuncture , and self-care education . One study showed that reflexology on the feet had no effect on pain and functioning . The beneficial effects of massage in patients with chronic low back pain  lasted at least 1 year after the end of the treatment . Two studies compared 2 different techniques of massage . One concluded that acupuncture massage produces better results than classic ( Swedish ) massage and another concluded that Thai massage produces similar results to classic ( Swedish ) massage . Conclusion . Massage might be beneficial for patients with subacute and chronic nonspecific low back pain , especially when combined with exercises and education . The evidence suggests that acupuncture massage is more effective than classic massage , but this need confirmation . More studies are needed to confirm these conclusions , to assess the impact of massage on return-to-work , and to determine cost-effectiveness of massage  as an intervention for low back pain Low back pain is one of the most common and important musculoskeletal disorders . In addition , chronic low back pain can deteriorate the patient 's physical , psychosocial and socioeconomic status . The objective of this quasi-experimental research was to assess the efficacy of an aerobic exercise and health education program in the treatment of chronic low back pain .  Seventy-two patients whose ages ranged from 30 to 50 years who had chronic low back pain were enrolled and r and omly assigned into two groups . Eight men and 28 women in the experimental group participated in a series of 3 health education sessions and an aerobic exercise training program . Nine men and 27 women in the control group received regular health education and a lumbar flexion exercise program . After a 3-month period of treatment , the results revealed the experimental group had statistically significant improvement of pain score and resting pulse rates when compared to the values of the control group ( p-value < 0.001 and < 0.01 , respectively ) . The average serum High Density Lipoprotein-Cholesterol ( HDL-C ) in the experimental group was also significantly higher ( p-value < 0.05 ) than that of the control group . This health education program is useful and may be applicable to patients with chronic low back pain  as an alternative treatment Abstract Objective To estimate the effect of adding exercise classes , spinal manipulation delivered in NHS or private premises , or manipulation followed by exercise to “ best care ” in general practice for patients consulting with back pain . Fig 1 Progress of the UK BEAM trial Design Pragmatic r and omised trial with factorial design . Setting 181 general practice s in Medical Research Council General Practice Research Framework ; 63 community setting s around 14 centres across the United Kingdom . Participants 1334 patients consulting their general practice s about low back pain . Main outcome measures Scores on the Rol and Morris disability question naire at three and 12 months , adjusted for centre and baseline scores . Results All groups improved over time . Exercise  improved mean disability question naire scores at three months by 1.4 ( 95 % confidence interval 0.6 to 2.1 ) more than “ best care . ” For manipulation the additional improvement was 1.6 ( 0.8 to 2.3 ) at three months and 1.0 ( 0.2 to 1.8 ) at 12 months . For manipulation followed by exercise the additional improvement was 1.9 ( 1.2 to 2.6 ) at three months and 1.3 ( 0.5 to 2.1 ) at 12 months . No significant differences in outcome occurred between manipulation in NHS premises and in private premises . No serious adverse events occurred . Conclusions Relative to “ best care ” in general practice , manipulation followed by exercise achieved a moderate benefit at three months and a small benefit at 12 months ; spinal manipulation achieved a small to moderate benefit at three months and a small benefit at 12 months ; and exercise achieved a small benefit at three months but not 12 months
Interventions such as supervised or individualised exercise therapy and self-management techniques may enhance exercise adherence .
BACKGROUND Chronic musculoskeletal pain ( CMP ) is a major health problem , accounting for approximately one-quarter of general practice ( GP ) consultations in the United Kingdom ( UK ) .
Exercise and physical activity is beneficial for the most common types of CMP , such as back and knee pain .
However , poor adherence to exercise and physical activity may limit long-term effectiveness .
OBJECTIVES To assess the effects of interventions to improve adherence to exercise and physical activity for people with chronic musculoskeletal pain .