Low back pain just walks away

A cheap intervention doubled the time to recurrence and halved the need for time off work.

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Walking can be a cheap and powerful weapon against low back pain, reducing recurrence and stretching the time to recurrence of serious episodes, a new Australian study has found.

The WalkBack study, led by Dr Natasha Pocovi (PhD) at Macquarie University, randomised 700 adults to either an individualised, progressive walking intervention that included six sessions with a physiotherapist, or a control arm with no treatment.

Participants had to have recovered from an episode of non-specific low back pain in the previous six months; they had to be able to walk but not be walking or doing other regular moderate-to-vigorous physical activity three or more times a week.

The no-treatment control was selected as “the most important, practical, real-world comparison to the intervention”, the authors write. Patients in that arm were free to seek out any prevention strategies or treatment they liked during the trial.

The walkers received five health coaching sessions in the first three months with a booster at six (largely via telehealth as the study took place during covid). Their target was to be walking for 30 minutes five times a week by the end of the six months, but this was tailored to each patient’s situation. They were all given a pedometer and asked to keep a walking journal for 12 weeks, and to continue if they found them motivating.

After three months they were instructed to wear a hip-worn triaxial accelerometer for seven days.

The walkers were also given education that “aimed to provide a basic understanding of modern pain science and reduce fear associated with low back pain. Simple strategies to reduce the risk of a recurrence of low back pain and instructions on how to self-manage any minor recurrences were discussed.”

Days to recurrence of low back pain (rating at least 2 out of 10 and lasting at least 24 hours) were recorded as the primary outcome, and they were followed up for between 12 and 36 months.

The median days to a recurrence was 208 days for the walkers and 112 days for the controls. The walkers reduced their risk of recurrence and care-seeking for recurrence by 20% compared with controls. They also had better outcomes on disability and quality of life.

The walkers gained more QALYs than the control group, and a health economic evaluation found the intervention cost-effective.

Similar numbers in each group reported an adverse event, though there was a trend among the walkers “towards a greater number of adverse events related to the lower extremities” – presumably foot and ankle injuries or pain – “and fewer events related to low back pain than in the control group”.

Dr Pocovi said this kind of intervention was cheaper and more accessible than comparable interventions previously explored and should be easily scalable.

“It not only improved people’s quality of life, but it reduced their need both to seek healthcare support and the amount of time taken off work by approximately half,” she told media.

Co-author Professor Matt Hancock, professor of physiotherapy at Macquarie, said the reasons for the benefits of walking on back pain were not precisely known.

“It is likely to include the combination of the gentle oscillatory movements, loading and strengthening the spinal structures and muscles, relaxation and stress relief, and release of ‘feel-good’ endorphins,” he said.

“And of course, we also know that walking comes with many other health benefits, including cardiovascular health, bone density, healthy weight, and improved mental health.”

The Lancet, 19 June 2024