Exercise-based and pain education program for adults with chronic low back pain in Brazilian Primary Care: feasibility study

Santos, Ana Ellen do Nascimento; Cacau, Catharina Saraiva Nobre; Nunes, Ana Carla Lima; Jesus-Moraleida, Fabianna Resende de

doi:10.5935/2595-0118.20220032-en

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ORIGINAL ARTICLE • BrJP 5 (02) • Apr-Jun 2022 • https://doi.org/10.5935/2595-0118.20220032-en linkcopy

Exercise-based and pain education program for adults with chronic low back pain in Brazilian Primary Care: feasibility study

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND AND OBJECTIVES Low back pain is the leading cause of disability in Brazil. Most of the evidence on interventions for chronic low back pain (CLBP) comes from high income countries. The objective was to investigate the feasibility of conducting a program based in exercise and pain education in Primary Health Care supported by low-cost mobile technology for adults with CLBP (versus waiting list) and to explore the profile of patients who adhered compared to those who did not adhere.

METHODS This is a feasibility study with adult residents of Fortaleza, Brazil with CLBP. The Intervention Group consisted of strategies such as physical exercises, pain education, phone calls and support messages to participants. The Control Group was based on a waiting list. Primary outcomes included retention and adherence rates, comprehension of the intervention, credibility, and satisfaction with the intervention. Secondary outcomes included clinical and demographic factors such as pain intensity, disability, recovery prognosis, and physical activity, described according to adherence behavior.

RESULTS Forty-five individuals were allocated to the Intervention Group and 24 to the Control Group. Overall, 57.8% of participants adhered to the intervention. Retention rates were 53.33% and 58.3% for intervention and control, respectively. The other primary feasibility outcomes were satisfactory. Longer time spent sitting and level of schooling differed the profile of those who adhered to the intervention from those who did not. Higher pain intensity and poorer recovery prognosis, measured at baseline, influenced non-adherence to home exercises.

CONCLUSION The feasibility of the protocol was adequate for the comprehension of the components, however, adherence to the protocol and the follow-up of the participants were low. The profile of individuals adhering to the intervention includes higher schooling and more time spent sitting at baseline. Characteristics such as higher pain intensity and the influence of psychosocial factors influenced non-adherence to home exercises. Brazilian Registry of Clinical Trials (REBEC RBR-5wqr2j).

Keywords:
Low back pain; Primary Health Care; Treatment adherence and compliance

Week	Educational component	Exercise component	Mobile technology component
1	Subject: Comprehending LBP; Topics: Definition of pain, factors influencing pain, types of pain and transition, neurophysiology of chronic pain, prognosis, first line of care for CLBP, myths about LBP. Delivery of booklet.	Group training: Controlled breathing, lumbopelvic mobility exercise and progressive muscle relaxation; Home exercises: GTE.	Text message: Reminder for relaxation attitudes and pain relief techniques; Telephone call: advice for proposed exercises and support for doubts and difficulties.
2	Subject: Importance of movement. Topics: Definition of movement, repercussions on the body, ways to move, kinesiophobia, effects of inactivity, pain cycle and benefits of physical exercise for pain, walking program.	Group training: Week 1 exercises, preferred direction, bridge and walking; Home exercises: GTE.	Text message: Reminder of the benefits of becoming active and effects of inactivity and encouragement to exercise; Telephone call: Advice for exercises and support for doubts and difficulties.
3	Subject: Gradual exposure to activities; Topics: Impact of CLBP on daily activities, definition, goals and strategies of gradual exposure.	Group training: Week 2 exercises, gradual exposure to the specific activity indicated and squatting; Home exercises: GTE.	Text message: Reminder and encouragement of the importance of physical activity; Telephone call: Advice for exercises and support for doubts and difficulties.
4	Subject: Importance of planning; Topics: What is planning and why, strategies for organizing activities and exercises, balance between activity and rest, respect for limits and appropriate pace, goal setting and action plan.	Group training: Week 3 exercises, lower limb abduction; Home exercises: GTE.	Text message: Reminder and encouragement to set goals and achieve objectives; Telephone call: Advice for exercises and support for doubts and difficulties.
5	Subject: What have we learned so far? Topics: Review of exercise benefits and harms of inactivity, reinforcement of planning and importance of progressing exercises.	Group training: Week 4 exercises and partridge exercises; Home exercises: GTE.	Text message: Encouragement and example of simple habit changes to exercise more; Telephone call: Advice for exercises and support for doubts and difficulties
6	Subject: Testing what was learned; Topics: All topics covered above.	Group training: Progression of the Week 5 exercises; Home exercises: GTE.	Text message: Encouraging exercises and monitoring directed to goal achievement; Telephone call: Advice for exercises and support for doubts and difficulties.

Outcomes	Instruments/measures	Time
Retention	Percentage of reassessed individuals, based on the number of individuals allocated to each group.	T₂
Adherence to treatment	Percentage of individuals attending more than 75% of the face-to-face sessions, considering those allocated to the program.	T₂
Adherence to home exercises	Exercise adherence is defined by the extent to which the patient performs the exercises prescribed by a professional. Perceived home exercise adherence was evaluated with the question: “How much of the prescribed home exercises do you consider you’ve performed?”. Scale of 1-5 points, where 1: “I did not perform the exercises”; 2: “I’ve performed the exercises the minority of the times”; 3: “I’ve performed the exercises moderately”; 4: “I’ve performed the exercises most of the time”; 5: “I’ve always performed the exercises as prescribed by the physical therapist”.	T₂
Difficulty in comprehending the intervention	Difficulty was assessed with the question: “How much difficulty did you have comprehending some information/content during training?”. Scale of 1-5 points, where 1: “No difficulty”; 5: “Extreme difficulty”³⁰.	T₂
Difficulty in comprehending the execution of exercises	Difficulty was assessed using two questions, “How much difficulty did you have comprehending the exercises?” and “How much difficulty did you have performing the exercises at home”? Scale of 1-5 points, where 1: No difficulty; 5: Extreme difficulty³⁰.	T₂
Credibility	Participants assessed the degree of credibility with the question, “How much credibility does the proposed intervention have?”. Scale of 1-5 points, where 1: “No credibility”; 5: “Extreme credibility”³⁰.	T₂
Satisfaction	Participants rated the degree of satisfaction with the question “How satisfied are you with the physical therapy treatment?”. Scale of 1-5 points, where 1: “Very dissatisfied”; 5: “Very satisfied”³⁰.	T₂
Adverse Events	Recording of the patients’ spontaneous report to therapists during the intervention.	T₃
Pain intensity	Numerical Pain Rating Scale NPRS (0-10 points, where zero = no pain; 10 = worse imaginable pain at the time of assessment)³¹.	T₁, T₂
Disability	Roland Morris Disability Questionnaire (RMDQ) - 0-24 point scale, where the higher the score, the higher the disability³².	T₁, T₂
Self-efficacy	Chronic Pain Self-Efficacy Scale (CPSS) - Divided into three subscales: self-efficacy (SE) for pain management, SE for physical function, and SE for coping with symptoms. Each question has answering options ranging in a score from 10 to 100 within a Likert-type scale. The total score of the questionnaire can range from 30 to 300 points, the higher the score the better the individual’s SE³³.	T₁
Kinesiophobia	Tampa Scale of Kinesiophobia - Composed of 17 statements with four response options each, whether totally agree, partially agree, totally disagree or partially disagree. Its score ranges from 17 to 68 points³⁴.	T₁
Level of physical activities	International Physical Activity Questionnaire (IPAQ). It consists of eight questions about days and time spent in the last week doing moderate and vigorous activities and walking. The time spent sitting on a normal weekday and at the weekend is verified. The score for each activity is given in Metabolic Equivalents of Tasks (MET) and individuals are classified as insufficiently active, moderately active, or very active. The result of the time spent sitting is given in minutes. This variable does not affect the individual’s physical activity level results.³⁵	T₁
Trunk mobility	Fingertip-to-floor Test (FFT). Quantifies the trunk mobility of an individual during an anterior trunk flexion using a tape measure, measuring the distance in cm between the finger and the floor. The higher the result in cm, the lower the mobility³⁶.	T₁
Prognosis of recovery	START Back Screening Tool (SBST). Assess the risk of poor prognosis of recovery from LBP, composed of 9 questions: questions 1 to 4 are related to pain and disability, and questions 5 to 9 are related to psychosocial factors. The score ranges from 0 to 9 and classifies the individual into high, medium, or low risk for poor recovery prognosis.³⁷	T₁

Variables	Intervention Group (n=45)	Control Group (n=24)
Gender (n, %)
Female	30 (66.67)	17 (70.83)
Male	15 (33. 33)	7 (29.17)
Mean age (±SD), in years	43.49 (±14.91)	47.66 (±17.72)
Marital status (n, %)
Single	24 (53.33)	9 (37.50)
Married	15 (33.33)	10 (41.67)
Schooling (n, %)
Complete elementary school	12 (26.67)	7 (29.17)
Complete Secondary education	17 (37.78)	6 (25.00)
College degree	13 (28.89)	10 (41.66)
Postgraduate degree	3 (6.66)	1 (4.17)
Family income (n, %)
Up to 1 minimum-wage	17 (37.78)	7 (29.17)
From 1 to 2 minimum-wages	19 (42.22)	13 (54.17)
More than 2 minimum-wages	9 (20.00)	3 (12.50)
Comorbidities (n, %)
None	10 (22.2)	6 (25.00)
Up to two	23 (51.11)	11 (45.83)
More than two	12 (26.67)	6 (25.00)
Use of analgesic drugs (n, %)
Yes	21 (46.67)	14 (58.33)
No	24 (53.33)	10 (41.67)
Physical exercise practice (n, %)
Yes	17 (37.78)	10 (41.6)
No	28 (62.22)	14 (58.33)
Pain intensity (±SD), 0-10 points	4.51 (±2.87)	4.91 (±2.98)
LBP disability (±SD), 0-24 points	14.20 (±5.38)	14 (±5.64)
Level of physic activity (LPA; n, %)
Low	15 (33.3)	7(29.2)
Moderate	22 (48.8)	10(41.6)
High	7 (15.5)	7 (29.2)
Total IPAQ-MET	1826.13 (±2078.41)	2149.37 (±2403.67)
IPAQ sitting week/min	299.27 (±172.16)	339.79 (±171.57)
IPAQ sitting weekend/min	323.36 (±175.52)	302.5 (±178.88)
Kinesiophobia (±SD) (17-68)	45.82 (±7.76)	41.08 (±5.89)
Self-efficacy
Total self-efficacy (±SD) (30-300)	185.52 (±47.99)	192.24 (±40.29)
Self-efficacy for pain management (±SD) (10-100)	61.24 (±19.45)	66.25 (±17.17)
Self-efficacy for physical function (±SD) (10-100)	64.69 (±22.49)	66.23 (±16.71)
Self-efficacy when dealing with other symptoms (±SD) (10-100)	58.32 (±16.10)	59.76 (±16.24)
Recovery prognosis (SBST)
Total SBST (±SD) (0-9)	5.33 (±2.17)	5.04 (±2.19)
Total psychosocial SBST (±SD) (0-5)	2.75 (±1.50)	2.75 (±1.45)
Trunk movement, in cm (±SD)	21.28 (15.38)	23.77 (±12.56)

Variables	GAi (n=26)	GNAi (n=19)	GAe (n=19)	GNAe (n=5)
Age	43.88 (±15.1)	43.32 (±15.11)	44.32 (±16.197)	39.60 (±13.428)
Female gender (n, %)	16(61.5%)	14(73.7%)	11(57.9%)	3(60%)
Physical exercises practice - (NO) (n, %)	16(61.5%)	11(57.9%)	11(57.9%)	3(60%)
Low schooling (elementary school) (n, %)	3(12%)*	8(42.1%)	19(100%)	5(100%)
Family income > 1 minimum wage (n, %)	17(65.3%)	11(57.9%)	3(15.7%)	2(40%)
Drug use (YES) (n, %)	12(46.1%)	11(57.9%)	6(31.5%)	4(80%)
Pain (0-10) (±SD)	3.88 (±2.56)	5.26 (±2.97)	3.21 (±2.573)*	6.00 (±1.581)
Disability (0-24) (±SD)	14.35 (±5.60)	14.00 (±5.20)	13.63 (±5.44)	15.40 (±6.22)
Kinesiophobia (17-68) (±SD)	46.23 (±7.66)	45.26 (±8.06)	45.37 (±8.11)	46.40 (±5.41)
Self-efficacy
Total self-efficacy (30-300) (±SD)	185.44 (±48.96)	185.63 (±45.22)	191.90 (±52.944)	158.98 (±35.312)
Self-efficacy for pain control (10-100) (±SD)	60.46 (±20.25)	62.31 (±18.80)	61.053 (±22.064)	57.600 (±16.211)
Self-efficacy for functionality (10-100) (±SD)	66.36 (±21.34)	62.41 (±23.79)	69.532 (±21.251)	53.334 (±23.359)
Self-efficacy when dealing with other symptoms (10-100) (±SD)	58.65 (±17.62)	57.87 (±13.71)	61.315 (±18.173)	48.250 (±16.830)
Level of physical activities (IPAQ)
Total IPAQ/MET(±SD)	1457.44 (±1642.64)	2330.67 (±2471.21)	1514.44 (±1844.74)	1283.80 (±1189.71)
IPAQ sitting week/min (±SD)	374.58* (±202.16)	248.49 (±162.07)	393.11 (±222.66)	366.00 (±116.96)
IPAQ sitting weekend/min (±SD)	380.35 (±211.81)	297.65 (±162.59)	397.32 (±225.48)	336.00 (±156.46)
Recovery prognosis (SBST)
Total SBST (0-9) (±SD)	5.46 (±2.19)	5.16 (±2.19)	4.74 (±2.15)*	7.20 (±1.30)
Psychosocial SBST (0-5) (±SD)	2.85 (±1.48)	2.63 (±1.57)	2.37 (±1.38)*	4.00 (±1.00)
Trunk mobility in cm (±SD)	24.06 (17.03)	19.21 (14.36)	21.71 (±15.89)	33.40 (±23.23)

Outcomes	Intervention Group (n=24)	Control Group (n=14)
Pain intensity (0-10) (±SD)	1.39 (±1.61)	4.28 (±3.07)
Disability (0-24) (±SD)	3.96 (±5.51)	12.50 (±4.94)

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Categorical variables are expressed as numbers and percentages. Continuous variables are expressed as mean and standard deviation (SD). MET = metabolic equivalent of task; Min = minutes; SBST = Start Back Screening Tool; IPAQ = International physical activity questionnaire