Exercise prescription for chronic back or neck pain: who prescribes it? who gets it? What is prescribed?

Exercise is a common treatment for individuals with chronic low back or neck pain and is used to improve physical function and decrease symptoms (e.g., pain, stiffness). Exercise has also been used to minimize disability by decreasing individuals’ fears about pain during movement and by reshaping their attitudes and beliefs about their pain. The latter goal is common in cognitive behavioral and functional restoration programs that typically use a quota-based, non-pain contingent approach to exercise.1 In the past decade, a number of randomized trials, systematic reviews, and clinical practice guidelines have supported the use of exercise for the treatment of chronic low back pain (LBP) 2–14 and chronic neck pain.15–19 While there is still much to learn about the types and intensity of exercises that are most effective, recent meta-analyses by Hayden and colleagues suggest individually tailored, supervised exercise programs that include stretching and strengthening are associated with the best outcomes for individuals with chronic LBP.5, 6 Hayden et al. also found that exercise in combination with other conservative treatments and “high dose” exercise, defined as an exercise intervention with a total time of 20 hours or more, improved pain and function more than exercise alone or “low dose” exercise.6 The findings for chronic neck pain are similar, though somewhat less definitive, with data suggesting that certain types of exercise are most effective and supervised exercise is more effective than non-supervised exercise. According to evidence statements on the treatment of chronic neck pain published by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain, supervised and home exercise plus advice is marginally more effective than advice alone for chronic whiplash associated disorders; a neck exercise program alone or in combination with spinal manipulation is more effective than spinal manipulation alone, TENS, or usual care for chronic “non-specific” neck pain; and both endurance (repetitive, submaximal resistance exercises) and strengthening exercises (repetitive, maximal resistance exercises) are effective treatments for chronic “non-specific” neck pain.19 Data also suggest that aerobic exercise and stretching alone are less effective than endurance and strengthening exercises,20, 21 and that stretching exercises for the neck are as effective as manual therapy.22 Evidence on the additive effect of other conservative treatments in combination with exercise for the treatment of chronic neck pain is less clear. There are some data to suggest that multimodal approaches that include exercise may be more effective than single treatment approaches.23, 24 While the past decade has led to gains in our understanding of the efficacy of exercise for chronic low back and neck pain, less is known about exercise prescription in routine clinical practice. Who is prescribing it? Who is getting it? What is being prescribed? Such information would be useful in assessing the translation of research findings to clinical practice and in identifying areas to target for increased promotion of exercise as an effective treatment. We analyzed data from a population-based survey of healthcare provider and treatment use by individuals with chronic low back or neck pain to gain a better understanding of the use of exercise in the treatment of these conditions. Our specific objectives were: 1) to determine the extent to which exercise is prescribed by physicians, physical therapists (PTs), and chiropractors for the treatment of chronic low back and neck pain; 2) to identify demographic, insurance, work, and health-related characteristics associated with exercise prescription; 3) to describe the amount of supervision provided and types of exercises prescribed for each provider type; and 4) to determine the extent to which other conservative treatments are used in combination with exercise.