The role of physical activity as a prognostic factor and treatment in the context of musculoskeletal pain

Author(s)

Crystian Bitencourt Soares de Oliveira

• Document type: Doctoral Thesis
• Press: Presidente Prudente. 2020-08-27.
• Institution: Universidade Estadual Paulista (Unesp). Faculdade de Ciências e Tecnologia. Presidente Prudente
• Defense date: 2020-07-10
• Advisor: Diego Giulliano Destro Christofaro; Rafael Zambelli Almeida Pinto

Abstract

Musculoskeletal pain is a prevalent condition responsible to high costs for the individuals and health care systems worldwide. Among the existent conditions, low back pain stands out for being one of the most prevalent musculoskeletal conditions and for leading the ranking of years lived with disability in Brazil and worldwide. Although physical activity-based treatments have been consistently recommended for treatment of musculoskeletal pain, there is limited evidence around the influence of physical activity and comorbidities due to the lack of physical activity in people with musculoskeletal pain. Therefore, this thesis aims to investigate the relationship between physical activity and factors related to the lack of physical activity with musculoskeletal pain, including low back pain. The objective of chapter 2 of this thesis was to conduct a systematic review to investigate the prognostic role of physical activity in the course of low back pain. Identifying factors that influence the course of low back pain is important to help clinicians to identify those patients at higher risk of non‐recovery. Included studies were heterogeneous in terms of physical activity assessment, outcomes, follow‐up duration, and statistical methods, therefore, pooling of results was not performed. Our review identified limited evidence supporting physical activity as a prognostic factor in low back pain. From a primary care perspective, the co-occurrence of chronic musculoskeletal pain and cardiovascular diseases would reveal a need to develop new preventive and treatment strategies that address cardiovascular diseases and associated risk factors in addition to reducing pain and disability. In chapter 3 of this thesis, we investigated the magnitude of the association between cardiovascular disease and chronic musculoskeletal pain. We found high-quality evidence that people with chronic musculoskeletal pain are 1.91 times more likely to report having a cardiovascular disease compared with those without chronic musculoskeletal pain (risk ratio = 1.91; 95% confidence interval: 1.64–2.21). Our findings demonstrated associations between chronic musculoskeletal pain and any cardiovascular diseases. Since 2001, overviews comparing clinical practice guidelines for the management of patients with non-specific LBP in primary care settings have been conducted with the objective of summarising the consensus messages and differences between clinical practice guidelines. Therefore, the aim of chapter 4 was to update the last version of the overview published in 2011 investigating the recommendations regarding the diagnosis and treatment contained in current clinical practice guidelines for patients with non-specific low back pain in primary care. For diagnosis of patients with non-specific low back pain, the clinical practice guidelines recommend history taking and physical examination to identify red flags, neurological testing to identify radicular syndrome, use of imaging if serious pathology is suspected (but discourage routine use), and assessment of psychosocial factors. For the treatment of patients with acute low back pain, the guidelines recommend reassurance on the favourable prognosis and advice on returning to normal activities, avoiding bed rest, the use of nonsteroidal anti-inflammatory drugs and weak opioids for short periods. For the treatment of patients with chronic low back pain, the guidelines recommend the use of nonsteroidal anti-inflammatory drugs and antidepressants, exercise therapy, and psychosocial interventions. In addition, referral to a specialist is recommended in case of suspicion of specific pathologies or radiculopathy or if there is no improvement after 4 weeks. Although the efficacy of physical activity-based interventions in reducing pain and disability is well recognised, it is still uncertain the effects of physical activity interventions increase objectively measured physical activity levels of patients with chronic musculoskeletal pain (e.g., osteoarthritis, low back pain) compared to no/minimal intervention. Therefore, in chapter 5, a systematic review with meta-analysis was performed which identified low quality of evidence suggesting that these interventions may lead to little or no difference in objectively measured physical activity levels of patients with chronic musculoskeletal pain compared with no/minimal interventions. Besides of the effects on physical activity levels, it’s also uncertain the effects of physical activity-based interventions using electronic feedback in reducing pain and disability compared to minimal or no interventions in patients with chronic musculoskeletal pain. In another systematic review reported in chapter 6, we identified only four published randomized controlled trials and 4 registered unpublished randomized controlled trials were included. Our results suggest that physical activity-based interventions using electronic feedback may be ineffective in reducing pain and disability compared to minimal interventions in patients with chronic musculoskeletal pain. After an extensive review of the available literature, we found that the effect of treatments using exercise therapy on pain and disability are at best moderate and not sustained over time. One of the reasons can be related to the limitation of current exercises programmes for chronic LBP is that these programmes are not designed to change patients’ behaviour toward an active lifestyle. Therefore, in the chapters 7 and 8 of this thesis, we investigated the short- and longterm efficacy of the addition of health coaching and the use of an activity monitor (i.e. Fitbit Flex) to the supervised exercises compared to a group receiving only supervised exercises on physical activity levels, pain intensity and disability, in patients with chronic, nonspecific LBP. Outcome measures were analysed by blinded assessors at baseline and 3, 6 and 12 months postrandomisation. The primary outcomes were physical activity, measured objectively with an accelerometer measured 3 months post-randomisation as well as pain intensity and disability at 3 months post randomisation. One hundred and sixty adults with chronic, nonspecific LBP were recruited and randomly allocated into two groups. Regarding the self-reported assessments, 139 (87%) participants completed the 3-month follow-up assessment, 107 (67%) participants completed the 6-month follow-up assessment e 111 (69%) participants completed the 12-month follow-up assessment. In the assessments using the accelerometer, there were a high proportion of invalid data at follow-up assessments and, therefore, we reported only the results for the self-reported outcomes. There were no differences between groups in the 3, 6 and 12 months follow-up for any primary or secondary outcome. The addition of health coaching to the supervised exercises was not able to reduce pain intensity and disability levels of patients with chronic low back pain when compared to the placebo group. (AU)

• FAPESP's process: 16/03826-5 - Investigating the effect of a physical activity intervention enhanced with health coaching and FitBit on physical activity levels of patients with chronic low back pain: a randomized controlled trial
• Grantee: Crystian Bitencourt Soares de Oliveira
• Support Opportunities: Scholarships in Brazil - Doctorate