Exercise Benefits for Chronic Low Back Pain in Overweight and Obese Individuals

Accepted Manuscript Exercise Benefits for Chronic Low Back Pain in Overweight and Obese Individuals Joseph G. Wasser, Terrie Vasilopoulos, Laura Ann Zdziarski, Heather K. Vincent PII:

S1934-1482(16)30227-1

DOI:

10.1016/j.pmrj.2016.06.019

Reference:

PMRJ 1733

To appear in:

PM&R

Received Date: 1 February 2016 Revised Date:

9 June 2016

Accepted Date: 14 June 2016

Please cite this article as: Wasser JG, Vasilopoulos T, Zdziarski LA, Vincent HK, Exercise Benefits for Chronic Low Back Pain in Overweight and Obese Individuals, PM&R (2016), doi: 10.1016/ j.pmrj.2016.06.019. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Exercise Benefits for Chronic Low Back Pain in Overweight and Obese Individuals R1

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Joseph G. Wasser, Terrie Vasilopoulos, Laura Ann Zdziarski and Heather K. Vincent

Department of Orthopaedics and Rehabilitation, Division of Research; Interdisciplinary Center for Musculoskeletal Training and Research, University of Florida, Gainesville, Florida

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June 9, 2016

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Corresponding Author:

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Heather K. Vincent, Ph.D.

Department of Orthopedics and Rehabilitation, Division of Research UF Orthopaedics and Sports Medicine Institute (OSMI)

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PO Box 112727

Gainesville, FL 32611

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Office Phone: (352) 273-7459 FAX: (352)-273-7388 [email protected]

Running head: Obesity, pain and exercise solutions

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1 2 Exercise Benefits for Chronic Low Back Pain in Overweight and Obese Individuals

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Running head: Obesity, pain and exercise solutions

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Abstract

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Overweight and obese individuals with chronic low back pain (LBP) struggle with the combined

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physical challenges of physical activity and pain interference during daily life; perceived disability

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increases, pain symptoms worsen, and performance of functional tasks and quality of life (QOL)

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decline. Consistent participation in exercise programs positively affects several factors including

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musculoskeletal pain, perceptions of disability due to pain, functional ability, QOL, and body

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composition. It is not yet clear, however, what differential effects occur among different easily

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accessible exercise modalities in the overweight-obese population with chronic LBP. This narrative

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review synopsizes available randomized and controlled, or controlled and comparative studies of

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easily-accessible exercise programs on pain severity, QOL, and other outcomes, such as physical

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function or body composition change, in overweight-obese people with chronic LBP. We identified

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16 studies (N=1,351) of various exercise programs (aerobic exercise [AX], resistance exercise [RX],

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aquatic exercise [AQU], and yoga- Pilates) that measured efficacy on LBP symptoms, and at least

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one other outcome such as perceived disability, QOL, physical function and body composition. RX,

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AQU, and Pilates exercise programs demonstrated the greatest effects on pain reduction, perceived

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disability, QOL, and other health components. The highest adherence rate occurred with RX and

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AQU exercise programs indicating that these types of programs may provide a greater overall impact

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on relevant outcomes for overweight-obese LBP patients.

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Key words: exercise, low back pain, obese, outcomes, overweight

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Introduction

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The one-year global prevalence of low back pain (LBP) is 38%, with the highest rates occurring in

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women and persons aged 40-80 years.[1], Population incidence of LBP is directly associated with

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body mass index (BMI); moreover, risk factors for LBP include overweight and obesity.[2] Obesity

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is defined as a BMI exceeding 30 kg/m2 and overweight is defined as a BMI of 25-29.9 k/m2.[3]

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Currently, 37.7% of all American adults are obese,[4] and racial and ethnic minorities are still

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challenged by rising rates.4 The direct relationship between LBP incidence and BMI[5] is

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strengthened with more time being physically inactive.[6] Obese people with persistent LBP face

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profound functional limitations[5] and a high comorbid burden.[7] Physical inactivity over the long-

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term accelerates disability onset, functional dependence, and early mortality.[8]

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People suffering from chronic LBP have lower aerobic power,[9] restricted mobility in part due to lower passive hip extension range of motion,[10] lumbar muscle atrophy, and excessive

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muscle fatigability.[11] Over activation of lumbar extensors may occur leading to premature

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fatigue in these muscles; thus, the spine may be more susceptible to shearing and torsional

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loads.[10] Ambulatory ability, gait speed, and relative muscle strength of the lumbar extensors[12]

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and lower extremity muscles are compromised.[13] The collective physical impairments coupled

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with pain-related discomfort interfere with quality of life (QOL) and self-efficacy for pain and

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physical function.[14] Moreover, continued fear avoidance beliefs toward exercise likely contribute

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to the chronicity of pain.[14]

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Regular exercise participation is a primary prevention against more than 35 chronic

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conditions including obesity and joint pain,[15–17] and reduces mortality risks independent of

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weight loss.[18] Yet, fewer than 50% adults in most countries fail to participate in exercise

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consistently to maintain these protections.[19] This is a serious issue because inactivity worsens LBP

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pathology, physical deconditioning and weight gain.[14] Inactivity narrows intervertebral discs and

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increases paraspinal muscle fat content, pain severity and disability level.[20] Clinical exercise

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programs for LBP have been extensively investigated, but relatively few have focused on overweight

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individuals or the QOL outcomes. Isolated therapeutic exercises,[11,21] manual therapies,[22–24]

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and exercise with combined treatments (nutrition, cognitive behavioral, complementary/ alternative,

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modalities)[23–26] are among the numerous programs studied. Investigations have found varying

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effectiveness of different exercise programs on pain relief, and some programs have potential for

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significant healthcare cost savings.[27] Figure 1 provides a proposed pathway of overweight-obese

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people who remain inactive compared to those who become engaged in regular exercise. Sedentary

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behavior initiates a cycle of worsening LBP, and contributes to deconditioning, fear avoidance

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behaviors and functional limitations.[15] Over time, continued weight gain and worsening fear of

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movement increases perceived and actual disability and QOL. Participation in regular exercise can

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disrupt this cycle by improving pain symptoms, physical function, and fear avoidance behaviors.[28–

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30] As self-efficacy and fitness improve, participation exercise for longer durations can increase

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energy expenditure and fitness levels.[31] The result is better LBP control, perceptions of

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functionality and QOL.[32,33]

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The challenge for clinicians is to prescribe exercise that can help this population overcome LBP and engage in life activities. While research shows positive benefits of different exercise

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programs on health outcomes in overweight people with LBP, the sustainability of these programs

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outside the clinical research setting is questionable due to personal cost, stigma, and access to

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facilities or trainers. Furthermore, due to the heterogeneity of the research exercise interventions,[34]

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there is not yet a consensus on the exercise program type that are most effective and accepted by the

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overweight patient. The latest evidence for exercise effectiveness may help clinicians prepare

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exercise prescriptions for this expanding demographic. The purpose of this review is to provide the

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highest quality evidence of easily accessible exercise programs on pain severity, QOL, and outcomes

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such as physical function or body composition change in overweight-obese people with chronic LBP.

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Methods

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Search Process. A narrative literature review involved a search using PubMed was conducted to identify articles of exercise programs for chronic LBP in overweight and obese persons

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that were published in English between the years 1980-2015. The research cohorts had to include

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adults (persons≥18 years), with general, chronic diffuse LBP (pain persisting for ≥3 months) who

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were overweight or obese (body mass index [BMI] ≥25kg/m2). Selected research designs were

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randomized and controlled, or controlled and comparative. While numerous studies have focused on

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isolated exercises or physical activity components as part of an overall intervention (e.g., behavioral

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therapies, modalities, injections or surgery), it is challenging to separate out the exercise effects on

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the outcome of interest. As such, at least one study arm of the article had to be a as standalone

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intervention not coupled with other treatments that was not just a cluster of physical therapy

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exercises. These exercise arms included aerobic exercise (walking, cycling), resistance exercise (free

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weights, machines), aquatic exercise, yoga or Pilates. Many research efforts have focused on LBP

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relief, not on overall musculoskeletal health.[33] Studies that were included had to report a minimum

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of changes in LBP severity (e.g., 11-point visual analogue scale [VAS], or other instrument pain

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subscale), and one secondary outcome such as changes in perceived disability due to low back pain

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(Oswestry Disability Index [ODI], Roland Morris Disability Questionnaire [RMDQ]), functional

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assessment (Quebec Back Pain Questionnaire, muscle strength, endurance, flexibility tests), quality

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of life (Medical Outcomes Short Forms), or fear avoidance behaviors. We selected exercise programs

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that can be performed in local fitness centers, gyms, senior activity centers, neighborhoods and at

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home

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The search terms “body mass index”, “low back pain”, “exercise” initially resulted in 96

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articles. Additional search terms were added to improve our catchment such as “obese”, “obesity”,

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“randomized controlled study” and this number increased to 224 articles. All articles were reviewed

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by the authors to determine suitability for inclusion. A total of 16 studies were included, although

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several high quality clinical trials had to be excluded from analysis due to several reasons: no control

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group[35], participants did not meet the BMI minimum of ‘overweight’ status,[36–40] or body mass/

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BMI was not reported,[41–49] a lack of key outcome measures,[27] poorly defined exercise

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program,[50] or the integration of exercise with other cognitive behavioral components or dietary

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modification and could not be separated.[51–53] These 16 randomized, controlled and comparative

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studies are summarized in Tables 1-4.

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Results

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Synopsis of Exercise Modes. The main exercise modes consisted of aerobic exercise (sustained

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repetitive motions of large muscle groups sufficient to increase heart rate), resistance exercise (the

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use of weight or resistance to overload muscle), aquatic exercise (sustained repetitive motions,

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flexibility or strengthening in water) and yoga-Pilates.

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Aerobic Exercise (AX). Two studies used walking as a primary AX modality, with sample

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sizes of 52 and 246.[54,55] The first study compared six months of a graded walking program that

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followed American College of Sports Medicine guidelines (self-managed walking program recorded

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in a diary, adjusted weekly by physiotherapist; moderate intensity exercise at ~40% up to 60% heart

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rate reserve) to an exercise class (“Back to Fitness” program) and usual physiotherapy controls in

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patients with LBP.[54] Outcomes were the numerical pain rating scale, ODI scores, fear avoidance

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behaviors, health-related quality of life (EuroQOL EQ-5D-3L weighted health index) and health

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service cost. Outcomes were analyzed on an intent-to-treat premise. Over six-months, all three

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groups demonstrated similar reductions in resting LBP severity. More patients in the walking group

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achieved a ≥30% improvement in the ODI than the exercise class and physiotherapy control groups.

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These ODI responders had greater reductions in pain severity and fear avoidance scores. All three

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groups made minimal improvements in the EuroQOL scores, Back Beliefs and exercise self-efficacy.

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Cost analysis showed that the average cost per participant in the “Back to Fitness” class was the

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lowest compared to the walking group and usual physiotherapy (€156.02 versus €177.33 and

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€229.88). LBP improved in all three interventions, but the authors proposed that more emphasis on

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addressing fear avoidance beliefs may foster improvements in exercise self-efficacy and LBP beliefs. A second study compared walking exercise to an active movement exercise group

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(progressive, low-load upper and lower body, trunk exercises) on LBP.[55] Outcomes included LBP

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functional scale, functionality (six-minute walk test, trunk flexor-extensor endurance), perceived

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disability (ODI) and fear avoidance beliefs-physical activity. Analyses were conducted on an intent-

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to-treat basis. Significant improvements were made in all outcomes in both groups, with no

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differences between the two treatment groups. The active movement and walking groups improved

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six-minute walk test distances by 9.7% and 16.4%, and decreased ODI by 30.5% and 34.3%,

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respectively. Attrition rates were 23% and 11% in the exercise groups. A possible interpretation is

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that both walking and active movement exercise group both sufficiently activated superficial and

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deep trunk muscles which permitted similar gains in trunk muscle endurance.

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Aquatic Exercise (AQU): Two studies compared the effectiveness of short-term AQU

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training to control groups[32,56] and one compared different doses of AQU to non-exercise

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control.[57] Sample sizes of these studies ranged from 32 to 74. The basis for this modality is to

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offload axial compressive forces while maintaining a movement resistance stimulus and joint range

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of motion during muscular contractions. Through the effects of buoyancy, activities can be

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performed that would otherwise be too painful or impossible on land.[57] Secondary health benefits

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of AQU include cardiovascular conditioning, body composition change, lowered cardiometabolic

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disease risk and strength.[57,58]

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Baena-Beato et al. tested whether 40 sessions of AQU over two months had superior effects

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to no-exercise.[32] Outcomes included the ODI and SF-36, body composition and fitness (sit-and-

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reach test, abdominal muscle endurance, handgrip strength and estimated maximal aerobic fitness

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using the Rockport 1-mile walk test). Significant reductions in LBP severity occurred at rest and

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during flexion-extension movement by 62%-75% in the AQU compared to a small increase in the

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controls. Pain reductions paralleled improvements SF-36 physical component, aerobic fitness and

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body fat loss. There was a 12.5% attrition rate in the AQU group due to time commitment. Despite

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favorable results, the authors admitted that this attrition may be due to the rigor of the program and

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may not be appealing to, or feasible for, the general public.

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The second study compared the effectiveness of an intensive three-month AQU program to a non-exercise control condition on LBP and body composition.[56] Key outcomes included

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the Keele Start Back Screening Tool score and the changes in body composition by month three.

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Compared to the control group, AQU achieved significant reductions in LBP physical and

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psychological symptoms by month three. Reductions in waist-to-hip ratio, percent body fat and

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body mass index ranged 5.6%-8.7% in AQU from baseline. Trunk muscle mass increased from

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25.4 kg to 26.5 kg but decreased only slightly in controls from 25.3 kg to 25.2 kg. Limitations of

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this study include the small sample size and study of men only. Further examination is needed to

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determine the actual mechanism of pain relief with weight loss.

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The third study was an 8-week dose-efficacy study of AQU exercise.[57] Adults with LBP

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were allocated to AQU exercise two or three days weekly, or to a wait-list control group. The same

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exercise components were present in each AQU session including resistance exercises of lower and

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upper body, aerobic exercises of jogging, leaping, arm push and pulls, leg crossovers, hopping in

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multiple directions, bounding off pool bottom, flexibility exercise cooldown. Outcomes included

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VAS pain ratings at rest and during lumbar flexion-extension, ODI scores, SF-36 scores, body

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composition using electrical impedance, and physical fitness (sit-and-reach test, handgrip strength,

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abdominal curl endurance and aerobic fitness for the 1-mile Rockport test). Attrition rates in the three

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groups ranged from 12.6% to 42.3%. AQU three days a week resulted in greater reductions in VAS

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pain at rest and during movement, ODI scores and SF-36 scores (physical component, bodily pain,

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physical role) than remaining groups. Of note, the high attrition rate in the exercise groups could be

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due to a large time commitment, loss of interest, or burnout from water activity. There were

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progressive improvements from AQU two to three times per week for changes in all functional tests,

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despite no changes in body weight or body composition. The importance of this finding is

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substantial. Overweight people in too much pain to engage in land exercise can use AQU instead.

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Resistance Exercise (RX): Resistance exercise training involves the use of body weight, free

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weights or machines to provide a resistance load for muscle groups. Multi-joint and single joint

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exercises can be used to stimulate large muscle groups around the hip, shoulder and chest and smaller

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muscle groups such as the triceps. Four studies compared resistance exercise interventions against

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either modalities, or different types RX programs on LBP severity and outcomes [33,28,59,60].

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Kell and Asmundson (2009) performed a four-month comparative effectiveness study of AX and RX modes on LBP symptoms, muscle strength, endurance (Biering-Sorenson Back Endurance

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test, abdominal curl up test), power and flexibility compared to a no-exercise control condition[33].

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Other outcomes included aerobic fitness, ODI scores and SF-36. Periodized RX involved variations

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in exercise intensity and set-repetition structure during the four months and the use of body weight,

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machines and free weights. Periodized AX consisted of variations of intensity and duration of

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selected aerobic activities (elliptical, treadmill walking and jogging). Most striking was the positive

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effect of RX on pain severity, ODI scores and SF-36 Physical and Mental component scores

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compared to AX and controls. VAS pain ratings were reduced by 39% and 7.8% in the RX and AX,

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respectively, from baseline. As expected, the AX group increased aerobic fitness more than RX or

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controls (19.4% versus 8.3% and -4.8%, respectively). Gains in strength, power and flexibility

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ranged from 10%-27% in the RX group, and from 3%-9% in the AX group. Despite the rigorous

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nature of the exercises, there were no adverse events reported. Key findings were: 1) LBP exercise

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programs should include varied RX exercises that engage a large portion of the musculoskeletal

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system, 2) periodizing a program provides stimulus change to the muscles that translates to better

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function, perceived ability and musculoskeletal health than a non-periodized program.1

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This same research team performed a subsequent, larger study to determine the dose effect of four months of periodized RX on LBP severity and related outcomes.[60] This work was the first to

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examine optimal RX dosage in this population. Participants were assigned to engage in RX 2 days, 3

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days or 4 days/ week. A non-exercise group served as controls. RX training involved 13 exercises

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performed in the exact order during each session that used body weight, machines and free weights to

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stimulate all the major muscle groups. There was a 13% attrition rate. Pain change was inversely

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related to changes in leg press, chest press and latissimus pulldown strength (r values -0.73 to -0.81).

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A significant dose effect was revealed: four days a week provided superior benefits for pain

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reduction, disability, quality of life and physical fitness to fewer days. In the 3 and 4 days/ week

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groups, body mass increased by 4.2%-4.4% and body fat decreased by 6.8%-8.7%, respectively.

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Controls had the lowest change of all four groups.

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Two studies of RX exercise for LBP in obese older adults were performed in our

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laboratory[28,59]. Adults 60-85 years with abdominal obesity with waist circumferences >88cm in

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women or >102cm in men, and chronic LBP were randomized to receive either a progressive, total

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body RX program with machines (10 upper and lower body resistance exercises including lumbar

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extension) or isolated lumbar extension RX for four months. A non-exercise, education group served

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as the control group. All participants received educational materials on safe physical activities and

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weight loss benefits. Main study outcomes were LBP at rest and during several functional tasks such

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as walking, stair climb and chair rise, gait. Other measures included perceived disability (ODI,

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RMQQ), fear avoidance beliefs and kinesiophobia, and pain catastrophizing. Overall, more profound

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improvements were made in outcomes with total body RX. Participants in the total body RX group

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achieved greater reductions in resting LBP severity[59]. Pain severity decreased with walking and

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chair rise by month four compared to the control group[28]. Pain catastrophizing and perceived

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disability improved in both RX groups compared to controls[28]. Some participants were ‘high

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responders’ to the RX, where lumbar extension strength gains exceeded 20% of baseline values.

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These high responders made greater gains in walking endurance and self-selected gait velocity and

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fastest walking velocity compared to non-responders, irrespective of which training group they were

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in. Two major findings were: 1) even without weight loss, RX improves pain severity, functionality

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and disability , and 2) inclusion of lumbar extension into a strength program is a key exercise

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component underlying these outcome improvements[59]. Similar to Kell and Asmundson, the use of

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total body RX rather than a core area alone may be an effective approach for addressing several key

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parameters in persons suffering from LBP[33].

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Yoga and Pilates. We identified seven studies of appropriate design and population, three of which involved two group comparisons of yoga or Pilates and a control group[47,61,62], and three

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compared yoga or Pilates to other exercise modalities[63–65]. One used a three-group design: a yoga

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group, aerobic-stretching exercise and a self-care control group[66]. Sample sizes ranged from

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20[61] to 228[66], and were conducted in the United States, Australia and the United Kingdom.

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The yoga studies were conducted using Iyengar yoga[47,61] and Hatha yoga[62]. Iyengar yoga emphasizes the appropriate alignment of the musculoskeletal system within each asana

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(posture) and may use props (e.g., chairs, belts or blankets) to accommodate tightness, structural

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imbalances or injuries and assists the individual to move into a posture properly. Hatha yoga involves

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asanas and pranayama (breathing exercises), which are used to instill peace and prepare the body for

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meditation. Cox et al.[61] and Williams et al.[47] examined the changes in LBP severity and related

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outcomes with 12 once-weekly Iyengar classes, or 48 biweekly classes, respectively. Both studies

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utilized an intent-to-treat analysis of outcomes. First, Cox et al. administered a program consisting of

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13 different class themes and measured the key outcomes of LBP severity (0-100 point Aberdeen

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back pain scale), quality of life (SF-12), self-efficacy and medication use for pain.[61] Participants

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in the yoga group demonstrated a significantly greater reduction in pain than usual care (“The Back

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Book” providing general guidelines for back health). No other group differences were detected for

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the remaining outcome measures. This was attributed to low power, pain interference with correct

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alignment and inclusion of several complicated standing asanas that required skill levels above the

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capacity of the participants. Second, Williams et al. administered a program consisting of 31 different

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yoga postures assessed VAS pain ratings, ODI scores, depression levels and medication use.[47]

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LBP severity progressively decreased by 26% and 42% from 12 to 24 weeks of participation of yoga

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compared to the control group. Similarly, ODI scores and Beck Depression Inventory scores

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continued to decrease over the same time frame. A trend toward successful pain medication

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management was detected, where the yoga group tended to report lowering medication dosage,

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frequency and /or amount of medications needed for pain control. There were 10% and 18% attrition

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rates for the two studies, with more dropouts the longer the time frames. The success of these Iyegnar

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programs on outcomes may be due in part to use of the variety of equipment to help with support and

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traction and avoidance of back bending poses. Third, a six-week pilot study compared effectiveness

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of Hatha yoga twice a week on LBP, ODI and flexibility tests compared to a control group.[62]

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Outcomes were reported as change scores and were dichotomized to indicate whether improvement

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occurred or not. The program included diaphragmatic breathing and gentle standing and stretching

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postures, and preparatory exercises (tree, triangle, hand to foot posture, sitting postures, cobra,

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forward bending postures, twisting and half spinal twist), Sun Salutation, and relaxation/ meditation.

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At week six, there were no differences in the outcome changes between the two groups for the study

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outcomes. Among those participating in yoga, 54% and 46%, reported lower depression scores and

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ODI scores compared to 20% and 40% in the control group. Flexibility measures improved in 64-

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90% of people in the yoga group compared to 20% of the controls. While 54% percent of the yoga

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group indicated sustained improvement in back pains severity by month three, and 72%

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recommended yoga to others, none of yoga group continued the activity after the study.

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In another study, the effects of a 12-week Viniyoga class intervention on back pain,

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perceived disability, activity restriction, satisfaction and global rating of improvement were

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compared to two other interventions: 1) an exercise-stretching class, and 2) self-care (control; “The

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Back Pain Helpbook”). The yoga class consisted of performing 17 postures with variations and

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adaptations, and guided deep relaxation. The exercise-stretching class involved aerobic exercise, 10

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strengthening exercises and 12 stretches. Outcome measures were collected via telephone by masked

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interviewers. Adjusted analyses revealed that both the yoga and the stretching groups reported

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superior function (lower RMDQ scores) than the self-care group at completion and 6 months of

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follow-up. Significantly more people in the yoga and stretching groups improved their RMDQ scores

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by 30%-50% at the end of the study and at follow-up compared to self-care. Yoga alone reduced the

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low back ‘pain bothersomeness’ score more than self-care at week 12. Compared with self-care, yoga

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and stretching class participants were more likely to report higher global satisfaction and that their

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back pain was better, much better or completely gone at months 3 and 6.5. Overall yoga was not

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found to be more effective from stretching than a self-care book in most outcomes.

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Three short-term studies compared the effectiveness of Pilates to either general exercise programs[64,65] or to stationary cycling.[63] Wasjwelner et al. used individual delivery of a Pilates

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program and a general low-back exercise program to participants.[65] Outcomes included numerical

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pain rating scores, Quebec Back Pain Questionnaire scale and the SF-36.[65] Aside from three SF-36

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subscores, the two groups attained similar improvements in all outcomes by the completion of the

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study and at follow-up. Mostagi et al. also administered individual exercise sessions for their Pilates

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and general exercise groups in their study.[64] The primary outcome was VAS pain rating.

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Secondary outcomes included the Quebec Back Pain Questionnaire and hamstring flexibility in a sit-

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and-reach test, and the Sorensen lumbar extensor endurance test. While both groups attained similar

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reductions in LBP, greater improvements in function (Quebec Questionnaire) and hamstring

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flexibility occurred over time in the general exercise group versus Pilates. Finally, Marshall et al.

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implemented Pilates and stationary cycling in a class format.[63] Each program contained eight

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focus-areas and monitored intensity using heart rate and ratings of perceived exertion. Key outcomes

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were VAS pain ratings, ODI scores, Pain Catastrophizing Scale scores and Fear Avoidance Beliefs

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Questionnaire scores. At week 8, the Pilates group demonstrated greater reductions in VAS ratings

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and ODI scores than the cycling exercise group. These differences were no longer present at week 24

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of follow-up. While pain catastrophizing was reduced over time in both exercise groups, fear

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avoidance beliefs were not. Exposure to moderate-to-vigorous activity of either exercise likely helps

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people overcome negative perceptions of LBP sufficiently to stay engaged in exercise and feel less

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disabled. At month six, 59%-64% of the groups reported ongoing participation in exercise.[63]

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Evidence Summary. The evidence suggests that after about four months of RX, two months of

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AQU, or three months of Pilates significant reductions in pain, perceived functional limitations, and

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increased strength were observed. Figure 2 provides an overview of the studies reviewed here. First,

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back pain severity ratings generally decreased more with AQU, RX, Pilates, yoga and general

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exercise (mean pain decrease range of 35.5% -56.2% for the studies included) compared to AX

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modes such as walking and cycling (mean pain decrease of 11.4%).[54,55] This finding may be the

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result of more extensive engagement of lumbar extensor muscles and complementary core-hip

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muscles in the former exercise modes which could synergistically support the lumbar spine and

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reduce pain. The fact that addition of total body strength exercise inclusive of targeted back

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extension exercises can enhance pain relief in the obese individual[28] supports this concept.

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Second, all exercise types, including the general exercise comparators in specific studies,

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decreased perceptions of disability due to LBP.[33,60] However, more pronounced improvements in

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perceived disability generally occurred with yoga-Pilates, RX and AQU (36%-76.1%)

328

[47,28,60,63,64,66] compared to AX and stretching (19.7%-27%)[63,66]. These findings suggest

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that perceived disability may be positively influenced by complex muscle activation patterns and

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muscular fitness rather than aerobic fitness or muscle flexibility in this population. There may be a

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direct translation of exercise-induced functional strength gains to enhanced performance of daily

332

activities in the home or community. Better performance of daily activities facilitates positive

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feelings of accomplishment and lowers perceived disability. Third, QOL tended to increase more

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with RX, AQU or Pilates [33,32,57,60,65] compared to AX and yoga interventions[33,60,61]. RX-

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induced improvements in Physical and Mental Components of the SF-36 ranged from 7.4% to

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30.7%[33,60,65]. Greater improvements in QOL occurred with more weekly RX sessions.[60]

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Possible mechanisms underlying these positive changes include decreased pain catastrophizing

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[28,63] and fear avoidance beliefs[28] and improved pain efficacy[65].

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Among the studies reviewed, exercise provided benefits that are important for management of obesity and related comorbidities. For example, AX, periodized RX and AQU significantly

341

reduced body fat (2-3.9%)[33,32,57] and AQU lowers waist-to-hip ratio by 7.3%.[56] Reduction of

342

centrally-deposited body fat confers anti-inflammatory benefits and contributes to musculoskeletal

343

pain relief[67], and reduces future risks for cardiovascular disease and diabetes. Aerobic fitness

344

increased with AQU (39.0%)[32], and enhanced fitness reduces the risks for all-cause mortality.[18]

345

Gains in function, such as flexibility, gait speed, muscle endurance, muscle power and

346

strength[33,57,59,60,64] may transfer to anatomical and physiological readiness for more strenuous

347

functional activities or participation in recreational activities and sport. Figure 2 provides a synopsis

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of the effects of different modalities on LBP in the overweight-obese patient.

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Safety and Adherence. All exercise modalities appeared to be well-tolerated and safe. The

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most common adverse event was mild-to-moderate worsening of LBP severity, which occurred in

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9%-14.9% of the study groups. Pilates and yoga were associated with temporary cessation of

352

exercise (3-4 days) due to increased pain severity before resuming.[28,65] The affected participants

353

increased pain medication dosage and/or received treatment for shoulder pain.[65] [28,65,66] Some

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participants had to stop the program to receive medical intervention.[28] Attendance of >80% of

355

exercise sessions was achieved by 55% Pilates[64,65] and 49% in general exercise.[64] Adherence to

356

yoga interventions was sporadic.[61,66] Walking, AQU and RX were associated with relatively

357

higher adherence rates (74.8%-100%)[54,57,28,59], indicating that these exercise modes could

358

consistently be performed by this population. Any of these exercises could be modified to adjust for

359

flare-up days.

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Future Directions. Additional research is needed to determine: 1) the optimal walking dosage for

362

outcome improvement, 2) differential effectiveness of walking on pain and disability in people with

363

different levels of pain catastrophizing or kinesiophobia, and 3) responsiveness to walking exercise

364

in individuals with different LBP pathologies and histories. Also, comparing effects of single and

365

multi-modal exercise in this population may reveal pain modulation differences. Comparison of

366

attrition and adherence rates and effectiveness of multi-modal versus single mode exercise programs

367

can provide clinicians with evidence-based strategies to treat this rapidly growing population. Future

368

research is warranted to identify the characteristics and physiological adaptations of the ‘responders’

369

to the different exercise treatments. As physiatry moves toward the personalized-medicine approach

370

for care, individualized prescriptions for exercise may be a successful method to manage LBP. Last,

371

the investigation of a transition approach to exercise over the long-term may provide better methods

372

for patient adherence. Development of strength with initial resistance exercise may enhance the

373

ability to participate in AX longer, a benefit which translates to more energy expenditure and lower

374

risk for cardiovascular and metabolic disease.

375 376

Conclusions. While weight loss is often the first and primary health aim for overweight and obesity,

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strength gains may also be an aim to induce the greatest functional outcomes these individuals with

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LBP. Resistive, Aquatic, and Pilates exercise programs appear to have the most effect on pain,

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perceived function, QOL, and other health components. Moreover, resistive and aquatic exercise

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programs had the highest adherence rates indicating that these types of programs may provide a

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greater overall impact on relevant outcomes for overweight-obese LBP patients. Given that 2-4

382

months of RX, AQU or Pilates can significantly reduce pain, strength and physical function, it may

383

be more desirable after this initial time period to slowly integrate aerobic exercises targeted at weight

384

loss. In this population it is imperative to first reduce LBP, pain related fears of exercise, and

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increase self-efficacy prior to focusing on aerobic exercise so that adherence to exercise program can

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be achieved and the benefits of long term participation in exercise can be obtained.

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Figure Legend

587 Figure 1. Proposed pathways of disability in overweigh-obese persons with chronic low back pain

589

(LBP), and how exercise may break the cycle of perpetual worsening of disability in this population.

590

The dark curved arrows represent the perpetual worsening of factors related to disability, whereas the

591

dotted curved arrows represent the pathway that could occur with engagement in regular exercise.

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Figure 2. Summary of the available evidence for different exercise modes on pain severity,

594

perceived disability, quality of life, functional outcomes, fitness and fear of movement.

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Table 1. Aerobic exercise (AX) exercise programs to treat LBP symptoms and key health prognostic factors in overweight and obese individuals. Exercise Components

Duration

Cohort

Hurley et al. 201547

Three groups • Walking group Up to 5 X/ week, 30 min • Exercise class Group-based circuit 1 X/ week, 1 hr each 10 exercises, education • Usual physiotherapy, control (CON)

6 months 12 month follow-up

N=246 adults aged 18-65 years

Shnayderman and Katz-Leurer 201248

Two groups • Walking, treadmill 2 X/ week, up to 40 min per session, low-mod intensity • Exercise group Low intensity strengthening exercise for trunk and limbs 2 X/ week, up to 40 min

1.5 months

Outcomes

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Study

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No differences existed among the three groups with respect to pain reduction (10.4% and 18.1% pain reduction in Exercise class and Walking versus 17.8% CON by month 6), perceived disability was 21.3% and 19.9% lower at month six for the Walking and Exercise class groups vs 12.0% in CON; all 3 groups made similar improvements in exercise self-efficacy

N=52 adults aged 18-65 years

No differences existed between the pain improvements at month 1.5 (15.3% exercise group versus 20.4% walking group); gains in six-minute walk test distance, perceived disability and trunk muscle flexor and extensor muscle strength were similar between groups; fear avoidance beliefs decreased more in exercise group than walking group (42.8% versus 17.0%)

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Table 2. Aquatic exercise (AQU) programs to treat LBP symptoms and key health prognostic factors in overweight and obese individuals. Exercise Components

Duration

Cohort

Baena-Beato et al. 201351

Three groups • AQU 2 times/ week 350 min aerobic exercise total 160 min flexibility total 48 sets resistance exercise total • AQU 3 times/ week 525 min aerobic exercise total 240 min flexibility total 78 sets resistance exercise total • Control group (CON)

2 months

N=74 adults aged 18-65 years

Baena-Beato et al. 201449

Two groups 2 months • AQU 5 times/ week/ 60 min each 875 min aerobic exercise total 400 min flexibility total 120 sets resistance exercise total • Control group (CON)

Irandoust &Taheri 201550

Two groups • AQU group session 3 days week/ 60 min • 2 aerobic sessions and 1 resistance exercise session of 8 exercises • Control group (CON)

Greatest rest pain reduction occurred with AQU 3 versus other two groups (60.9% versus 49.1% and 7.5% increase in CON); Pain relief with movement was highest in the AQU 3 group; Aerobic fitness values, walk speed muscle strength all improved most with AQU 3

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N=49 adults aged 18-65 years

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Outcomes

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Study

3 months

N=32 elderly men

LBP severity decreased by 38% at 2 months in AQU versus control which increased by 5%; perceived disability decreased by 56.3% in AQU; physical component of quality of life increased by 32% versus 4.8 with CON; the change in aerobic fitness was higher in AQU vs CON (36.6% vs – 6.3%); Handgrip strength, curl-up repetitions, sit and reach flexibility, muscle mass and body weight Improved more in AQU versus CON at month two. Reduction in the number of people reporting LBP symptoms at month 3 in AQU versus CON 57% fewer versus 14% fewer; Muscle mass increased and body fat decreased in AQU versus CON.

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Table 3. Resistance exercise-based (RX) exercise randomized controlled trials to treat LBP symptoms and key health prognostic factors in overweight and obese patients.

Kell & Asmundson 200927

Three groups • RX group 4 months 12 free weight and machine exercises, 2-3 sets per exercise 3 X week/53-72 min/ week at 53-72% of maximal strength • Aerobic exercise (AX) Any AX form, primarily walking or jogging 3 X week/ 85-155 min/week At intensity 10.5-13 on Borg scale • Control (CON)

Kell et al. 201155

Four groups • RX 2 days/ week • RX 3 days/ week • RX 4 days/ week All RX sessions 2-5 sets of six machines and 7 free-weight/ body-weight based exercises at 50-83% of maximal strength with 1-2 minutes rest between sets • Control group (CON)

Vincent et al. 201453

Three groups • Total body RX 10 machines including lumbar extension

Cohort

N=27 men and women aged 35-40 years

TE D 4 months

Pain and perceived disability decreased more in RX than AX by month 4 (pain by 38% versus 5.8%, and ODI by 40% and 9.6%, respectively); Muscle strength and sit- and-reach flexibility increased more in RX than AX and CON; quality of life scores were improved in RX more than AX or CON.

N=240 men and women aged 15-80 years

Compared to CON, the LBP severity was decreased from 14.2% to 28.0% (from 2 days to 4 days/ week) versus CON (2.2%); Greatest reductions in perceived disability in RX 4 days/ week, physical and mental quality of life components; Bench press lat pulldown and leg press strength gains were highest with RX 4 days/ week

N=49 older men and women

Pain medication number decreased in total body RX versus CON; Pain severity decreased most in total body RX group during walking and chair rise;

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4 months

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Three groups • Total body RX 10 exercises, including lumbar extension • Lumbar extension RX • Control group (CON)

RMDQQ, ODI and pain catastrophizing scores decreased most in total body RX.

N=49 older men and women 60-85 years

Ambulatory pain decreased by 42% (lumbar RX) and 58% (total body RX) compared to 7% in CON; Gait speed increased by 9% in total body RX vs 2.1% and -1.1% in lumbar RX and CON; 67% of TOTRX and LBRX made strength gains ≥20% than pre-training values.

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4 months

AC C

Vincent et al. 201454

60-85 years

RI PT

3 days/ week/ 1 set 15 reps • Lumbar extension RX 3 days week/ 1 set 15 reps • Control group (CON)

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Table 4. Yoga and Pilates exercise to treat LBP symptoms and key health prognostic factors in overweight and obese individuals. . Exercise Components

Duration

Cohort

Cox et al. 201056

Two groups • Iyengar Yoga 1 X week/ 75 min • Control group (CON) Written educational materials

12 weeks

N=20 adults aged 18-65 years

Galatino et al. 200457

Two groups • Hatha yoga 2 X week/ 60 min • Control group, wait list (CON)

6 weeks

Marshall et al. 201358

Two groups • Pilates 3 X week/ 50-60 min 8 components • Stationary cycling 3 X week/ 50-60 min 8 foci and pedal types

Mostagi et al. 201559

Two groups • Pilates 2 X week/ 60 min • General exercise, control (CON) 2 X week/ 60 min

Outcomes

RI PT

Study

TE D

M AN U

SC

Pain was reduced by 31% and 7% in the yoga and CON groups, respectively; Changes in perceived disability, quality of life and self-efficacy were not different between groups at week 12; The percentages of participants with LBP was 80 and 89 in yoga and CON groups.

AC C

EP

8 weeks 6 month follow-up

8 weeks 3 month follow-up

N=22 adults aged 30-65 years

A total of 54% of participants reported reductions in LBP after yoga; The yoga and CON groups had 15% less and 5.9% more perceived disability at week 6; Forward reach and sit-and-reach scores were 11.9% and 18.1% better in the yoga group, and 8% and 7.8% worse in CON group by week 6.

N=64 adults aged 18-50 years

Pain severity decreased more in Pilates than cycling group (39% vs. 18%); Perceived disability decreased more with Pilates than cycling (40.9% vs. 16.3%); More participants reported engaging in aerobic exercise at month 6 from the cycling group than Pilates (40% vs. 15%); Similar reductions in pain catastrophizing and fear avoidance occurred in both groups.

N=22 adults aged 18-55 years

Pain severity decreased in the Pilates and CON by 86.7% and 78.2%, respectively at week 8 (no difference); Pain stayed lower than baseline at month 3, no differences between groups; Perceived disability was better in CON than Pilates (60.2% vs

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42.6%); Sit-and-reach flexibility remained better in CON versus Pilates at month 3. 12 weeks 6.5 month follow-up

Wajswelner et al. 201260

Two groups • Pilates 2 X week/ 60 min, 6-12 exercises • General exercise, control (CON) Stationary cycle, leg stretches, upper body weights, Swiss ball, theraband and floor exercises

6 weeks 6 month follow up

Williams et al. 200940

Two groups • Iyengar Yoga 2 X week/ 90 min • Usual care, control (CON) Educational materials

N=228 adults mean age 48.4 years

M AN U

N=87 adults aged 18-70 years

Pain severity was reduced by 42.8% and 30% in Pilates and CON, respectively; Pain relief was maintained in both groups by month 6; Physical function increased more in Pilates versus CON (64.6% and 44.3%) by week 6 and improvements were maintained by month 6 (65.5% and 74.0%); Quality of life improved in both groups by week 6 and month 6.

N=90 adults 18-70 years

LBP severity decreased more in Yoga than CON by 24 weeks from baseline (56.8% vs 16.2%), this difference persisted at 6 months post; Perceived disability decreased more in the Yoga group (40.2% vs 8.1%) by week 24; The Yoga group showed a trend only in reducing the dose or number of pain medications.

TE D

EP

AC C

The percentages of participants whose pain was much better or gone in the Yoga, Stretching and CON were 60%, 46% and 16% by week 12; At month 6.5, 51% of both exercise groups reported improvement or resolution; a 30-50% improvement in perceived disability was better in Yoga and Stretching groups versus CON at both weeks 12 and 6.5 month; Similar percentages of participants in all three groups reported activity restriction (2-6%) and work loss (4-8%).

RI PT

Three groups • Viniyoga 12 classes/ 75 min • Stretching Aerobic exercise, 10 resistive exercises, 10 min for 12 stretches • Self-care book, control (CON)

SC

Sherman et al. 201161

24 weeks 6 month follow-up

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