The effects of walking on low back pain

Introduction[edit | edit source]

Low back pain that is not associated with serious or potentially serious causes has been described in the literature as 'non-specific', 'mechanical', 'musculoskeletal', or 'simple' low back pain.[1] Non-specific low back pain is defined as low back pain not attributable to a recognisable specific pathology (eg, infection, tumor, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome).[2]

Low back pain between the rib cage and gluteal folds

Lower back pain can be further split into three categories; acute, sub-acute, and chronic.[3]

  1. Acute is anything that persists for less than 6 weeks.
  2. Sub-acute is anything persisting between 6-12 weeks.
  3. Chronic is anything persisting for 12 weeks or more.

Lower back pain is commonly described to be between the anatomical regions of the ribs and gluteal folds.[4]

Anatomy Background[edit | edit source]

The lumbar spine comprises the lower end of the spinal column between the last thoracic vertebra (T12) and the first sacral vertebra (S1). There is a total of five lumbar vertebrae (L1-L5) that are much larger compared to other regions within the vertebral column. These large facets help support the upper body, as they absorb axial forces (against gravity) delivered from the head, neck, and trunk, and provide protection for the spinal cord from the canal that is formed. The lumbar spine allows for diverse types of trunk motion, including flexion, extension, rotation, and side bending, thus providing further reasons as to why the facets are much larger. Each lumber facet consists of multiple components; vertebral body, transverse process, super articular process, super articular facet, intervertebral disc, vertebral forearm, the pedicle of the vertebral arch, lamina of the vertebral arch, and a spinous process.[5]

Risk factors for lower back pain are age, sex, height, weight, sedentary lifestyle, depression, anxiety, insomnia, and smoking.[6] Although muscle strain and imbalance, ligament sprain, and soft tissue damage account for almost all lower back pain, as it is non-specific, it often has no identifiable underlying condition or origin[7]. Due to the complex structure of spinal components, discs, intervertebral joints, muscles, and nerves, lower back pain can present with the same symptoms for different causes.

Epidemiology[edit | edit source]

Low back pain causes more disability than any other condition, affecting 1 in 10 people and becoming more common with increasing age,[1]with rates of 1%–6% in children aged 7–10 years, 18% in adolescents, and a peak prevalence ranging from 28% to 42% in people between 40 years and 69 years.[8] The prevalence of LBP is thought to be increasing due to an increasing and aging population[9] with estimates of life time prevalence being as high as 84% in the adult population. [10]

One study that was carried out in 195 countries assessing the incidence, prevalence, and years lived with disability for 354 medical conditions found low back pain to be the leading cause of worldwide productivity loss as measured in years, and the top cause of years lived with disability in 126 countries.[8] In the United Kingdom (UK) it is estimated that low back pain is responsible for 37% of all chronic pain in men and 44% in women and the total cost of low back pain to the UK economy is reckoned to be over £12 billion per year[1].

Office workers are usually required to sit for long hours working on a computer while spending most of their time in a sitting position. Approximately 34%- 51% of office workers experienced LBP in the preceding 12 months. Occupational groups exposed to 'poor postures while sitting for longer than half a day have a considerably increased risk of experiencing LBP. Subjects with LBP are likely to be in sustained postures and have large and infrequent spinal movements. Prolonged postural loading of the spine while sitting can reduce joint lubrication, fluid content of intervertebral discs, and increased stiffness. Additionally to this, prolonged muscle activation in static sitting may lead to localised muscle tension, muscle strains, muscle fatigue, and other soft-tissue damage, causing impairment of motor coordination and control as well as increased mechanical stress on ligaments and intervertebral discs.[12]

Prevalence of walking in the United Kingdom:

  • People made an average of 236 walking trips and walked an average of 220 miles.
  • People on average have walked less than in 2019, following a fall in short walks.
  • People walked 7% farther in 2020 compared to 2019.
  • 67% of adults in England reported walking at least once a week.
  • 92% of local authorities had at least 60% of their adult population walking at least once a week.

The NHS provides a guide on 'walking for health', to help motivate the population and help them meet the recommended minimum moderate activity guidelines of 150 minutes.

Pedometer Driven Walking[edit | edit source]

Example of pedometer

Pedometers are a device that works by counting the steps someone takes to estimate the distance they have traveled. Pedometers are usually worn at the hip (on the waistband of clothing) and in alignment with the patella although this may not be the case for all pedometers. There are also other ways of tracking steps - many people now have fitness trackers which are attached to the wrist and will also have the ability to count steps.

Instructions will be included with pedometer devices, and as there are many different types it is important to check these before usage to ensure that the pedometer is being used as accurately as possible. Some pedometers may also be more complex and do a little bit more than just counting steps such as showing calories burned, activity times, and memory logs.

Whilst not a pedometer in the traditional sense, the NHS (National Health Service) also has an app which is free to download called 'Active 10' - this is designed to track walking and will indicate the total amount walked and how much of that was brisk walking. Within the app, there are also options to set goals, achieve milestones, and view progress over the weeks and months. So a pedometer is not the only option to keep a track of walking and daily activity - there are many more apps out there that will do the same thing!

Using an app as a pedometer or walking tracker does rely on the individual having a mobile phone and keeping it in their pocket to ensure it tracks all activity whereas a standard pedometer can be used by a wider number of people and may not be as complex.

Do Pedometers Increase Physical Activity?[edit | edit source]

The NICE (National Institute for Health and Care Excellence) guidelines on low back pain and sciatica in over 16s - published in 2016 and last updated in 2020 - advises self-management and exercise as treatments. [1]A pedometer would be an easy way of giving someone a tool to help self-manage their activity levels, as long as this was an appropriate choice of exercise for the individual - those with LBP should be encouraged to continue with their regular activities as well[1]

A three-arm cluster, randomised control trial (RCT) conducted in 2016 with an eventual number of participants at 956 recruited from primary care settings, found that a pedometer-based walking intervention (regardless of whether there was nurse support) increased the step count and physical activity of generally inactive 45-75 year old at a 12 month follow up.[13]A meta-analysis in 2009 of pedometer-based interventions for activity conducted in 2013 included 32 studies and found using pedometers to have a positive effect on physical activity and this was regardless of age or intervention length.[14]The studies had varying interventions from keeping a daily log of steps, completing 10,000 steps, individualized goals, or a combination of strategies.[14]

Do Pedometers Affect Low Back Pain?[edit | edit source]

Acute Low Back Pain (ALBP)[edit | edit source]

There is arguably less research in relation to acute back pain and the effects of using a pedometer. However, a study in 2015, focusing on those with ALBP of 48 hours or less looked at whether 'stay active' advice or 'adjusting activities to pain' had different effects. [15]Participants were aged between 18 and 65 and all were provided with a pedometer to track daily steps with the instruction of wearing it at all times during waking hours, they found the pedometer an easily used intervention which increased physical activity, particularly in those with the advice to 'stay active'.[15]This study shows that pedometers could have a useful place in treatment alongside other advice and management techniques for those with ALBP despite the study being over a short period of time, and the study size is relatively small.

Chronic Low Back Pain (CLBP)[edit | edit source]

As previously mentioned, CLBP accounts for a significant amount of chronic pain in individuals of the UK, so interventions that aid in the treatment and management would be beneficial. A recent RCT published in 2021, looked at the effects of a pedometer-driven individualized walking plan compared to standardised care in increasing completion and adherence of physical activity in CLBP management.[16]Whilst no significant difference was noted in disability or pain, there was an indication that using an individualised, guided pedometer program aided in adherence and participation of physical activity - although relevant measures such as step count were not taken from the standardised care group, so it is unclear if there were any increases in physical activity amongst them.[16]

A previous RCT from 2013, of an internet-based pedometer intervention, did find that in the short-term of 6 months back pain disability had decreased, but at 12 months there was no difference between the group with access to the internet support and the ones utilising the pedometer and standard management only.[17]Again, this shows, that whilst pedometer-driven walking can have positive effects in physical activity and adherence, there may need to be further research to explore how positive outcomes can be gained in the long term.

It seems that pedometers can be a relatively cheap and accessibly form of intervention and management in individuals with LBP, and this can have greater positive impacts when included with support in one form or another.[15]

Walking Effects on Low Back Pain[edit | edit source]

Walking dog.jpg

The lower back muscles play an important role in maintaining its stability and movement; two key aspects that are needed when walking [18]. These muscles can become deconditioned in those with sedentary lifestyles, leading to weakness over time. This prolonged weakness can increase muscular fatigue, and injury, exaggerating the pain already being experienced [18]. Reduced physical activity can also cause these muscles and the joints of the lumbar spine to become stiff, which can increase the pressure on the lower back [19].

Walking has many positive impacts on the lower back, which can prevent or reduce these changes occurring in the following ways:

  1. Increased blood flow:
    • Small blood vessels and capillaries in the lower back muscles can become constricted following decreased physical activity, reducing the blood flow to these muscles.
    • Walking allows for more movement in these muscles, allowing these capillaries and blood vessels to open up again.
    • This, in turn, increases the blood supply and nutrients to these muscles, improving muscular health and strength and aiding with the healing process [19].
  2. Stretch and contraction of muscles:
    • The movement in the lower back during walking increases the stretch and contraction of the lower back muscles and those in the legs, buttocks, and core, allowing for more flexibility and mobility in this area.
    • This flexibility increases the overall range of motion in the lower back, also improving the health and strength of the lower back muscles.

Current evidence supports the use of walking as a treatment option for low back pain. A cross-sectional study from 2017 evaluating the relationship between walking and low back pain, consisting of 5,982 adults, found that walking was associated with a reduced risk of low back pain [20]. The authors also found that the presence of low back pain was proportionate to walking frequency, with those who walked more often having reduced low back pain. These results are supported by those of a systematic review from 2019 evaluating the effects of walking on those with chronic low back pain [21]. Walking was found to be as effective as other non-pharmacological interventions on pain and disability in short-term (<3 months) and intermediate (3-12 months) follow-ups. These findings allowed for walking to be recommended for managing and treating low back pain [21].

The effects of walking have been compared to the effects of exercise for low back pain. A systematic review from 2019 comparing the two concluded that walking was as effective as exercise for improving pain, disability, quality of life, and fear-avoidance in those with chronic low back pain [22]. Much like the studies by Kim, et al (2019)[20] and Sitthipornvorakul, et al (2018)[21], Vanti, et al (2019)[22] recommend the use of walking as a treatment and management option for low back pain.

Interestingly, a systematic review from 2022, found that people with low back pain have altered gait patterns compared with healthy individuals [23]. Those with low back pain were found to walk slower, have reduced stride lengths, greater lumbar paraspinal activation, and reduced thorax/pelvic coordination [23]. However, the authors were unable to report if these changes were adaptive or maladaptive. Overall, these results indicate that gait re-education may be needed for those with low back pain to gain the most benefits from walking.

[24]

Treatment and Management[edit | edit source]

Effect Of Walking On Low Back Pain[edit | edit source]

A systemic review in 2015 concluded seven randomised controlled trials involving 869 participants adults with chronic low back pain. It compared walking to other non-pharmacological management methods such as usual care, specific strength exercises, medical exercise therapy, or supervised exercise classes. It suggested that walking is the same effective as other management methods while having a lower cost[25]. It could be explained by its high accessibility, but does not require training, supervision, or specialised equipment [25]

Other research supported that walking is as effective as conventional physiotherapy treatment such as lumbar stabilisation and muscle strengthening exercise [26][27]. A randomised included 48 participants comparing the effect of lumbar stabilisation exercise and walking exercise on low back pain. It suggested both interventions significantly reduced low back pain, and both interventions show similar results.[27]Another randomised control trial compare strengthening exercise to a combined program of strengthening exercise and walking exercise on chronic low back pain. It suggested that both interventions were beneficial but combined exercise program was more effective for reducing pain levels than the strength exercise.[26]Another randomised control trial also supported 44 participants comparing conventional physiotherapy to a combination of conventional physiotherapy with walking exercise. It suggested that a combination of conventional physiotherapy with walking exercise is more effective to reduces pain and kinesiophobia, and improved function in patients with subacute and chronic non-specific low-back pain[28].

How to use walking as a treatment for low back pain?[edit | edit source]

1. Combine with conventional physiotherapy treatment[edit | edit source]

As mentioned in the previous section, walking is a low-cost intervention, and a combination of physiotherapy with walking is more effective than conventional physiotherapy alone. [25][26][28]Therefore, walking exercise could by educated by physiotherapist alongside their exercise prescription. It is recommended to exercise for at least 15 to 30 minutes most days for those with low back pain[29]. So, this can mean gradually building up walking distance and capacity to reduce the risk of injury and allow for the body to adapt to the changes.

2. Goal setting[edit | edit source]

The use of a pedometer means that the patient is able to manage and keep track of their steps whilst walking. The patient might be advised to keep an "activity diary" which keeps track of a daily step count and the patient's step goal. This is achieved by calculating the patient's average step count in the first week of activity, and using this as a baseline when deciding a step goal for the second week [30]. The use of an activity diary can also help establish the patients' baseline in the first week, which is important in informing their individual goals for rehabilitation[30].

For example, use pedometer/tracking apps (like Active 10) to monitor and then set weekly targets (increase by a certain amount each week/two weeks for example)

3. Postural Control[edit | edit source]

Having the correct walking posture is important to allow for more comfortable walking, helping to reduce pain and discomfort. An optimal posture can be achieved using multiple strategies:

  1. Stand up straight:
    • This can be achieved by making yourself as tall as possible, without leaning forwards or backward.
    • Ensuring your chin is kept up and your eyes facing forwards allows for reduced strain on your neck and back.
    • These together will allow for a better posture and improved balance [31].
  2. Keep shoulders back and relaxed:
    • Relaxing your shoulders helps relieve tension and allows for a more neutral spine when walking.
  3. Engage core muscles and keep a neutral pelvis:
    • engaging your core and keeping a neutral pelvis prevents arching of the spine and tilting of the pelvis, allowing for a more neutral spine and better posture [32]."

Outcome measures[edit | edit source]

There are a variety of outcome measures that might be used when advising walking as a management strategy for patients with low back pain. These might look at:

  • Pain
  • Disability
  • Physical activity

Pain[edit | edit source]

The VAS (Visual Analogue Scale) is one of the most common outcome measures for low back pain [33].

It is an example of a subjective PROM (Patient Reported Outcome Measure), where the patient records their pain on a 100mm line- from "no pain" at the beginning to the "worst pain imaginable". Some types of VAS also use faces to represent pain from "mild", "moderate" to "severe", as shown below.

[34]Examples of a VAS

Previous studies have found that the VAS is a "reliable and valid" outcome measure for use in a low back pain population [35] . It has also shown reliability in predicting disability due to low back pain [36]

Disability[edit | edit source]

The Roland-Morris Disability questionnaire (RMDQ) is a commonly used PROM, designed to assess a patient's disability in relation to their low back pain. It is a 24-item questionnaire that looks at physical functions that the patient feels have been affected, and a higher score represents a higher level of disability due to low back pain [37].

An example of the RMDQ [38]

A study from 2020 found that the RMDQ had good test-retest reliability and internal consistency reliability in capturing the "everyday functional impact of low back pain" [39].

The Oswestry Disability Index (ODI) is also commonly used to assess functional disability in patients with low back pain [40]. It consists of 10 items which are detailed below, as well as the interpretation of the scores.

Oswestry Disability Index (ODI) [41]
Interpretation of ODI scores[42]

The ODI has been found to be a "valid and reliable scale suitable for measurement of disability for low back pain", and in particular showing high test-retest reliability[43].

A study looked at comparing the ODI and the RMDQ to each other. The study found that the ODI appeared to be better at detecting changes in patients with more severe lower back pain, whereas the RMDQ seemed to have an advantage when measuring patients who had more mild disability[44].

Physical activity[edit | edit source]

The International Physical Activity Questionnaire (IPAQ) is formed of two different versions including the IPAQ short-form and the IPAQ long version. Both versions require the patient to recall their physical activity levels in the past 7 days. Based on these scores, they are placed in one of three categories: low activity levels, moderate activity levels, and high activity levels [45].

The IPAQ short-form consists of 4 categories where the patient reports how much they participated in the following activities in the past 7 days:

  • Moderate activity
  • Vigorous activity
  • Time spent walking
  • Time spent sitting

The IPAQ short-form may be more beneficial for use in a clinical setting due to the shorter/more accessible nature of the questionnaire for patients[46].

The IPAQ long version assesses physical activity across 5 domains:

  1. Job-related physical activity
  2. Transportation physical activity
  3. Housework, house maintenance, and caring for family
  4. Recreation, sport, and leisure time
  5. Time spent walking

The IPAQ long version is typically used in research studies or may be used if a more detailed picture of a patient's physical activity levels is preferred[46].

Overall, the IPAQ has been subject to extensive reliability and validity testing across 12 different countries (14 sites) from 2000 as an outcome measure for physical activity.

Suggestions for Future Clinical Research[edit | edit source]

  • Based on the current literature, walking has been shown to be an effective management strategy for patients with low back pain. However, more high-quality RCT’s need to be carried out using a variety of outcome measures, including physical activity, to further investigate walking as an effective management strategy for low back pain.  
  • In order to strengthen the current evidence around this topic, further research could be carried out on how to ensure the long term effects of pedometer-based intervention. It would also be valuable to investigate whether added interventions might be necessary in aiding supportive positive outcomes long-term.
  • The current NICE guidelines for low back pain and sciatica were published in 2016 and updated in 2020 for pharmacological interventions. However, the advice for “non-pharmacological interventions” last had an evidence review in 2016. Therefore, it may be beneficial for a reassessment based on new evidence, in which guidelines around walking could be evaluated.

References[edit | edit source]

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