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Combined regimen reduces lower back pain

Lt. Col. John Childs, 81st Surgical Operations Squadron, demonstrates spinal manipulation for acute lower back pain on simulated patient Kevin Wait, a physical therapy clinic staff physical therapist.  (U.S. Air Force photo by Steve Pivnick)

Lt. Col. John Childs, 81st Surgical Operations Squadron, demonstrates spinal manipulation for acute lower back pain on simulated patient Kevin Wait, a physical therapy clinic staff physical therapist. (U.S. Air Force photo by Steve Pivnick)

GAINESVILLE, Fla. -- A regimen of core strengthening exercises was no better than traditional sit-ups for preventing back pain in soldiers, according to a new University of Florida study. But combining both exercise programs with a brief educational session on back pain strategies did lower the incidence of treatment for back pain.

The results of the study appear online in BMC Medicine, an open-access journal of BioMed Central.

Lt. Col. John Childs, Keesler's director of musculoskeletal research and a coinvestigator for the study, said low back pain is among the most frequent causes of medical visits and lost-duty time in the Military Health System

"Musculoskeletal pain, and especially low back pain, adversely affects military preparedness as common reasons for medical evacuation from ongoing conflicts, with return to duty being uncertain," said Childs, who holds a doctorate in physical therapy and serves as an associate professor with the U.S. Army-Baylor University doctoral program in physical therapy.

"It was our hypothesis that the core stabilization exercises would have some protective effect for back pain and maybe the combination of the core stabilization exercises and the education program would be the most effective, but as it turns out, adding the education to either of the exercise programs was the only place where we saw the benefit," said lead investigator Steven George, who also holds a doctorate in physical therapy. He's an associate professor in the UF College of Public Health and Health Professions department of physical therapy.

Core exercises target several different muscle groups that support the spine, including abdominal muscles, back muscles, side muscles, and muscles that attach to the pelvis. The military typically uses traditional lumbar training, which exercises only the abdominal muscles through a lot of sit-ups and crunches, George said.

"Core stabilization exercises are considered to be a more balanced approach to lumbar training so that's why we and others have thought that core exercises would be better at preventing back pain and that may be, but it just wasn't the case in this study," George said.

The Prevention of Low Back in the Military study involved 4,325 Soldiers stationed at Fort Sam Houston, Texas, who were completing a program for combat medic training. Participants were randomized by company into one of four treatment groups: core stabilization exercises, core stabilization exercises plus an educational session on back pain coping strategies, traditional lumbar exercises or traditional lumbar exercises plus the back pain educational session.

The exercise programs were completed as a group under the supervision of a drill instructor once a day, five days a week for 12 weeks. The education program consisted of one 45-minute group session led by study personnel that provided evidence-based information on low back pain and strategies for recovering from mild back injury.

"Part of the education is just to get people to understand the difference between when pain indicates true injury, which is usually only in the very early stages, and when pain is just a lingering signal, but you can still be active," George said. "We need to get people moving even when they're in pain because if we wait until they're pain-free, they can become deconditioned."

The researchers tracked participants' incidence of low back pain for two years following the intervention using a military health care utilization database. There was no difference in health care visits for back pain in the treatment groups who received exercises only, but among the groups who also received the educational program, there was a 3 percent decrease in seeking health care for low back pain. The decrease may seem small, researchers say, but because back pain is such a common health issue in the military, even a small decrease could lessen the burden on the health care system.

"Disease prevention is a fundamental tenet of modern health care but unfortunately efforts to prevent back pain have been largely unsuccessful because they were based upon anecdote and opinion rather than firm evidence," said Christopher Maher, director of musculoskeletal research at the George Institute for Global Health in Australia and a professor at the University of Sydney, who reviewed the journal article."What has limited progress in this field is a lack of prevention research; most trials in the back pain field evaluate treatment rather than prevention. The POLM trial is the back pain game changer. This trial will transform the approach to back pain prevention."

Future studies should investigate what cost savings may be attained through decreased health care visits for back pain, whether the educational program could benefit civilian populations and if the effects of the intervention could be greater if a more intensive education program was provided, researchers say.

The study was funded by the U.S. Department of Defense Peer Reviewed Medical Research Program of the Office of the Congressionally Directed Medical Research Programs.