Lifestyle Medicine, Behavioural Modification and Self Care for Managing Low Back Pain

Original Editor - Stacy Schiurring based on the course by Ziya Altug

Top Contributors - Stacy Schiurring, Kim Jackson, Wanda van Niekerk, Lucinda hampton, Jess Bell and Aminat Abolade  

Introduction

Low back pain (LBP) can be a complex and complicated diagnosis to treat. When looking for root causes of LBP, the physiotherapist must at times look beyond physiological causes and consider how the client's behaviours and social supports could be contributing to their LBP. Often a contributing source to a person's LBP is an outside pressure beyond their direct healthcare requirements. These needs reinforce the use of a biopsychosocial assessment approach for the treatment of chronic LBP. Preventative strategies and client education are important parts of physiotherapy care. Therapeutic interventions likely to reduce the chronicity of LBP may need to focus not only on biopsychosocial issues related to healthcare, but also wider social and lifestyle factors that may perpetuate LBP disability.

Behaviour Modification

Research suggests that modifiable risk factors may play a role in the development of LBP. A 2016 study published in Orthopedics identified nicotine dependence, obesity, depressive disorders, and alcohol dependence as statistically significant risk factors for the diagnosis of LBP.

Substance Dependence Disorder

Substance Dependence Disorder: an addictive  disorder of compulsive drug use. It is marked by a cluster of behavioural and physiological symptoms that indicate continual use of the substance despite significant related problems.

Consequences of substance abuse include:

1. Heart disease
2. Cancer
3. Stroke
4. Chronic obstructive lung disease
5. Cirrhosis
6. Familial, social, legal, and economic difficulties

Skillgate et al. looked at the effect of healthy lifestyle behaviour on chronic low back or neck pain in adults. The lifestyle factors were separated into healthy / non-healthy behaviours, and included: participation in regular moderate or high intensity exercise, daily smoking, amount of alcohol intake/week, and consumption of a healthy diet which included fruit and vegetables. The study found that persons who participated in three of four of these healthy lifestyle choices had protection from LBP in men and neck pain in women at a 4-year follow-up. The authors concluded the study with a recommendation for healthy lifestyle promotion and the need for further research into the effects of dietary components such as fish, whole grains, legumes, sweetened beverages, and sodium on the pathophysiology of pain.  

A 2010 meta-analysis of studies published in The American Journal of Medicine found that smoking might increase the risk of LBP, and the association is strongest for chronic or disabling LBP. Smoking cessation might reduce the risk of seeking care for chronic LBP. Further research is recommended between smoking prevention or cessation education and a reduced incidence or severity of LBP.  

A 2013 systematic review published in Manual Therapy identified that alcohol consumption is likely associated with complex and chronic LBP in persons with alcohol consumption dependence.  While further research is needed, this information can be used by physiotherapists as part of patient education for this population.

Making Changes from Addictive Behaviours

A habit is an overlearned process that generates automatic responses to contextual cues and is reinforced by repetition.

Transtheoretical Model of Change

General strategies for changing addictive behaviour:

1. Refer to individual or group counselling
2. Review patient's prescription and nonprescription medication, contact the referring physician with any concerns
3. Provide organisational contacts and resources
4. Use the Transtheoretical Model of Change to determine a person’s readiness for change
5. Use motivational interviewing as a part of your patient-centred counselling and treatments.

Smoking cessation strategies:

1. Hypnosis
2. Yoga
3. Positive psychology strategies and smartphone app use

Practical positive psychology concepts for promoting healthy lifestyle behaviours:  

1. Express gratitude for good things in their life
2. Savour successes and accomplishments
3. Engage in acts of kindness
4. Show forgiveness
5. Be involved in meaningful activities such as being a volunteer or mentor

Social Connectedness

Social connectedness: a positive subjective evaluation of the extent to which one has meaningful, close, and constructive relationships with other individuals, groups, or society.

Humans are social creatures. Research has shown that when lacking social connections, people may experience a reduction in overall health and well-being. This may include poor life satisfaction, depression, low self-esteem, decreased hope, an overall negative affect, and difficulty completing activities of daily living.

A 2018 article published in the Journal of Physiotherapy identified four areas of need that affect the ability of persons with LBP to comply with proper management of their pain. The four areas were pressures from work, financial pressures, social pressures, and difficulties with ADLs. When looking at social pressures specifically, the study found that persons with LBP felt strong social pressure to maintain employment. LBP was found to be a threat to social independence. Persons with LBP reported a disconnect from their social groups as a result of their pain. This shows the importance of social connectedness and the role social relationships plan in optimising well-being.

A systematic review and meta-analysis published in 2019 assessed factors affecting chronic LBP in the workplace. The researchers found significant evidence that psychosocial work factors such as employee high workload with low job control, and low social support can increase risks for developing chronic LBP. The review also noted that strong social support from work colleagues and supervisors can prevent or reduce the risks for chronic LBP.

Please listen to this 10 minute interview of Dr Martin Roland to learn more about the use of socially-oriented interventions in the UK.

Conventional Exercises

Tips to become more socially connected:

1. Engage in conventional group exercises
2. Engage in mind-body/integrative exercises
3. Join a gym or fitness centre
4. Enrol in art-based community activities
5. Volunteer
6. Create or join a lunchtime exercise group
7. Walk at a shopping centre
   

   Integrative Exercises
8. Create or join a community garden
9. Take classes to learn a new hobby or activity
10. Join self-help groups
11. Join social media platforms
12. Attend local sporting events or art performances
13. Connect with family and friends in person or over Zoom
14. Play with pets

Outdoor Natural Environments

Performing physical activity or exercise out in natural environments is called green exercise. Current evidence on green exercise shows benefits in three areas: immunological and physiological stress response regulation, psychological state, and participation in health-promoting behaviour.

A 2011 systematic review suggests that exercising in natural outdoor environments produces the feeling of greater energy, with reduced reported tension, anger, and depression as compared to performing the same exercises indoors. Participants also reported exercising outdoors increased participant intentions of repeat exercise sessions.

A 2019 randomised controlled trial by Huber et al. looked at the effect of green exercise on chronic LBP. The researchers found that a combination of daily moderate mountain hikes and thermal hydrotherapy soaks for six days showed significant improvements in pain, health-related quality of life and mental well-being.

A 2014 study looked at the effect of light therapy, produced by a light cabin, on chronic LBP. This treatment intervention has been found to be helpful in the treatment of depression, such as seasonal disaffective disorder. Pain and depression have been shown to have similar pathophysiological pathways and affected regions of the brain. The study found that light therapy could improve both depressive symptoms and reduce subjective LBP intensity, even in small doses. These results could be reproduced using a lightbox when either seasons or weather prevent outdoor exercise. When exercising or doing other activities outdoors, morning light provides the most benefits. For more information on this topic, please read Sunlight, Outdoor Light, and Light Therapy in Disease Management.

Integrative Lifestyle Medicine Treatment Examples

Poetry therapy is an adjunct therapeutic intervention often used in drug and alcohol programs. Please view this TED talk about poetry therapy being used with prison inmates.

Art therapy is another integrative therapy that can be used for mood and anxiety management. Please view this 9-minute video example of an art therapy session.

Music therapy is a complementary treatment that can be helpful in chronic pain management and its associated unwanted behaviours. Please view this video which discusses the fundamentals of music therapy.

Self Care and Self Management

Patient self care can be beneficial for successful outcomes of a multidisciplinary approach to pain treatments. A 2018 study published in Musculoskeletal Disorders found that most patients believed self care for musculoskeletal pain was effective, while healthcare providers support patient self care as an addition to skilled clinical management acting  as a placebo.

A 2019 systematic review published in Physiotherapy Theory and Practice found that physiotherapists are well aligned to empower self management of patient care for chronic conditions. Acknowledging a patient’s autonomy and humanity are key to supporting successful self-management approaches.

Self Management Strategies:

1. Activity pacing
2. Coping skills
3. Ergonomic set-up skills
4. Exercise programming
5. Flare-up management
6. Healthy lifestyle behaviours
7. Joint protection guidelines
8. Nutrition  screening and referral
9. Pain management
10. Problem solving skills
11. Relaxation activities
12. Resource utilisation skills
13. Self-monitoring skills
14. Self-tailoring skills
15. Sleep hygiene
16. Stress management
17. Time management

Resources

Tests and Measures (free for use):

• Readiness Ruler: a visual analogue scale for assessing a person's willingness to change behaviour.
• The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES): designed to assess readiness for change in persons with alcohol dependence.
• Social Needs Screening Tool: a simple questionnaire for determining social needs from housing to childcare to personal safety.
• The Social Connectedness Scale (Revised): a self assessment of how a person feels in and connects during social situations.
• UCLA Loneliness Scale (Revised): a self assessment of a person's subjective feelings of loneliness as well as feelings of social isolation.
• Morningness-Eveningness Questionnaire (MEQ): a self assessment which helps pin point a person's circadian rhythm.
• Seasonal Pattern Assessment Questionnaire (SPAQ): a self assessment of how behaviour changes over different seasons.

Useful Organisational Websites:

• Alcoholics Anonymous
• American Society of Addiction Medicine
• National Center for Complementary and Integrative Health
• National Institute on Alcohol Abuse and Alcoholism
• National Institute on Drug Abuse
• Smokefree
• Suicide Prevention Resource Center
• Association of Nature and Forest Therapy
• World Health Organization – Urban Green Spaces and Health
• Centre for Chronobiology
• Center for Environmental Therapeutics
• Icahn School of Medicine at Mount Sinai - Mount Sinai Light and Health Research Center
• National Institute of Mental Health - Seasonal Affective Disorder

• Society for Light Treatment and Biological Rhythms