Monday, May 9, 2016

Prescribing exercise to help back pain and decrease injurious falls

- Jennifer Middleton, MD, MPH

The current issue of AFP features the Top 20 Research Studies of 2015 for Primary Care Physicians, and two of the included studies discuss exercise's benefits: one for chronic low back pain and the other for decreasing the rate of injurious falls in older women. These studies provide specific recommendations to offer patients that can improve their quality of life.

The first study randomized patients with chronic low back pain to one of three treatments: an individual walking program, an exercise class, and physical therapy. Patients ranged in age from 18 to 65 years (mean around 45 years) and had at least 12 weeks of pain. As Drs. Ebell and Grad discuss in the AFP article, the walking program group cost the least, had the highest level of adherence, and resulted in the best improvements in pain and disability scores. Walkers received a pedometer and an exercise prescription to start with 10 minutes of walking 4 days a week, eventually working their way up to 30 minutes 5 days a week.

The second study examined the efficacy of exercise and vitamin D in home-dwelling women aged 70-80 years. Participants were randomized into four groups: exercise only, vitamin D supplementation only, exercise and vitamin D supplementation, and control (neither exercise or vitamin D supplementation). The two study groups that included exercise participated in group exercise classes twice a week for a year and then once a week after; on rest days, they had a home training program to follow. The researchers found no difference in the rate of falls per group but did find that participants in both of the exercise groups were much less likely to sustain an injury from their falls; the researchers defined an injurious fall as one where participants sought medical attention for anything from bruises to fractures. As an aside, they found no benefit for vitamin D, reinforcing what Dr. Lin recently wrote about vitamin D supplementation on this blog.

These two studies provide additional reasons to recommend exercise to two groups of patients: those with chronic low back pain and community-dwelling women aged 70-80 years. Providing an exercise prescription to patients that details your recommendations about aerobic, resistance, and flexibility training can increase adherence; you can see an example in Table 4 of this AFP article on Exercise and Older Patients. This article on Physical Activity Counseling includes an exercise calendar template (online Figure C) that may be useful for patients in the context of an exercise prescription, and this article on Promoting and Prescribing Exercise for the Elderly includes helpful strategies for counseling older adults.

To be effective, however, the United States Preventive Services Task Force (USPSTF) found that a minimum of 31 minutes of counseling was necessary to effect behavior change related to exercise habits. In the studies the USPSTF examined, physicians were usually not the providers of the counseling, and in-person and telephone counseling were both effective. This finding may feel discouraging, but family physicians can employ a team-based approach to helping patients increase their physical activity; physicians can initiate the conversation and explore readiness to change using motivational interviewing techniques before referring patients to a nurse or medical assistant educator to provide additional support.

Will these two "Top 20" studies change how you - and your office team - counsel patients about exercise?