Title: Correlates of low back pain: a closer look at physical activity, physical fitness and personal attributes
Other Titles: 'Determinanten van lage rugpijn: een nadere beschouwing van fysieke activiteit, fysieke fitheid en persoonlijke variabelen
Authors: Heneweer, Hans; S0020208
Issue Date: 4-Mar-2011
Abstract: Thesis Hans Heneweer, March 2011Correlates of low back pain: a closer look at physical activity, physical fitness and personal attributes SUMMARYLow back pain (LBP) is a very common disorder in the western industrialized world and one of the challenging problems in health care and society. LBP imposes a considerable social and economic burden on the community and is one of the most common reasons for presentations to primary health care providers. In this thesis some studies are presented to gain further insight into the role of two determinants relevant for both management and prevention of LBP: physical activity and psychosocial factors. The first studies are on physical activity. In the management of LBP, the significance of physical activity is generally accepted and an increase in the level of physical activity has become an important part of recommendations. However, the evidence of the contribution of physical activity to the prevalence, the prevention and management of LBP is still limited. Dose-response gradients are not similar to those in public health, because both physical activity and inactivity can represent a back risk factor.Therefore, we reviewed what is most recently known about physical activity (i.e. occupational load as well as non-occupational activities) as a risk factor for LBP. A systematic approach was used to explore the literature between 1999 and 2009 because the last review regarding this topic was published in1999. The results of our systematic review showed that the majority of the retrieved studies are focused on occupational workload. Only a few studies explored the association between physical leisure time (i.e. physical exercises) and LBP. No studies focused on the association between daily habitual physical activities (e.g. domestic work or commuting) and LBP. According to the reviewed literature, there is strong evidence that heavy physical workload and the exposure to awkward positions are risk factors. Inconsistent findings were found for leisure time physical activities, sports and physical exercise. We also explored the relation between type and intensity of physical activity, physical fitness and LBP. In public health the observation of physical activity is often done from the perspective of doing too little or not complying with recommendations. In occupational studies, physical activity is usually observed as doing too much or performing hazardous activities. Our study results showed that both extremes of the physical activity pattern are associated with a higher prevalence of LBP, suggesting that the relation between the intensity of activity and LBP follows a U-shaped curve. Because the validity of self-reports on physical activity is limited, we explored associations between more objective measures of physical fitness and LBP and found both muscular fitness and aerobic fitness (VO2 peak) strongly and inversely related with LBP. This finding might suggest that physical activity of an intensity that improves physical fitness is a key in the spectrum of physical activity to prevent LBP.A second theme of this thesis was the role of psychosocial factors for LBP. The focus was to explore to what extent psychosocial factors are related to both the experience of LBP and the transition from acute or subacute LBP to chronicity and long-term disability. Therefore, we looked at the psychometric properties of the Dutch language version of the Acute Low Back Pain Screening Questionnaire. The Acute Low Back Pain Screening Questionnaire (ALBPSQ) has been specifically constructed as a self-administered screening instrument, based on variables that have been suggested as a risk factor in the literature, but a psychometric validation of the Dutch language version of the ALBPSQ is lacking. We found the internal consistency and both construct and convergent validity sufficiently confirmed in a population of patients with (sub) acute LBP referred to primary care physical therapy in the Netherlands. Subsequently, we evaluated the transition from the stage of (sub)acute LBP to chronic LBP. The role of variables such as fear-avoidance beliefs, kinesiophobia and a passive coping style, as an expression of mal-adaptive behaviour in the stage of chronicity, is well documented. Our clinical question was aimed upon the role of these variables in the transition from the (sub)acute stage into the stage of chronicity. After the analysis of baseline scores (which were not predictive for delayed improvement after three months), we evaluated fear-avoidance beliefs, kinesiophobia and passive coping behaviour as being more an expression of adaptive behaviour rather than maladaptive behaviour in reaction to the experience of acute pain. This outcome endorses the clinical relevance of the critical appraisal of the time frame in which adaptive responses to acute pain turn into maladaptive behaviour. Catastrophizing about pain has been identified as one of the most important psychological variables in explaining responses to chronic pain. Most findings originate from the clinical environment and are well documented. Findings originating from the non-clinical environment are less documented. Accordingly, we studied the association between catastrophizing thoughts and self-rated back pain in a working population under non-clinical circumstances. Even after the adjustment for known covariates (e.g. physical activity, physical fitness, overweight, smoking, educational level and perceived work load) strong associations were found between scores on the Pain Catastrophizing Scale and self-rated back pain. It was concluded that the phenomenon of catastrophizing might be more an expression of a personal feature rather than a consequence of a certain pain perception or clinical and/or experimental setting. This underlines the clinical relevance for physicians and physical therapists in primary care of measuring and interpretation catastrophizing thoughts in the clinical process of managing LBP complaints.The finalchapter provides a critical appraisal of the research questions and a discussion of the key components shared by the studies of this thesis. Based on these findings, several recommendations for future research and clinical practice are made. First, there is need for further exploration of presumed associations between types and levels of physical activity and LBP. Especially within the domain of habitual and leisure time activities, there should be less restraint for the wider use of objective methods such as pedometers, accelerometers and heart rate monitoring. Furthermore, there is need for devices that enable us to measure back related activities under detrimental conditions, such as carrying heavy loads or the performance of activities in awkward positions. Secondly, research in the field of back pain is hampered by the lack of a uniform definition of LBP. If comparisons of study outcomes are to be used to investigate the causes and consequences of back pain, there is an absolute need for the standardization of back pain definitions and classification systems. Thirdly, it is of highest necessity to revise our view regarding the categorization of LBP into the time-based subclasses of acute, subacute and chronic complaints. This is because such a classification vies with our clinical experience and the outcome of studies and reports.Finally, physical therapists are challenged to rediscover a balance between the improvement of both the levels of motor control and physical fitness in patients with LBP as there are strong indications that the increase of physical fitness is inversely related with the prevalence of LBP.
Publication status: published
KU Leuven publication type: TH
Appears in Collections:Research Group for Cardiovascular and Respiratory Rehabilitation
Research Group for Musculoskeletal Rehabilitation

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