Detailed Search Results
| Author/Association: | Pocovi NC, Lin C-WC, French SD, Graham PL, van Dongen JM, Latimer J, Merom D, Tiedemann A, Maher CG, Clavisi O, Tong SYK, Hancock MJ |
| Title: | Effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention for the prevention of low back pain recurrence in Australia (WalkBack): a randomised controlled trial [with consumer summary] |
| Source: | Lancet 2024 Jul 13;404(10448):134-144 |
| Method: | clinical trial |
| Method Score: | 6/10 [Eligibility criteria: Yes; Random allocation: Yes; Concealed allocation: No; Baseline comparability: Yes; Blind subjects: No; Blind therapists: No; Blind assessors: No; Adequate follow-up: Yes; Intention-to-treat analysis: Yes; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed* |
| Consumer Summary: | RESEARCH IN CONTEXT: EVIDENCE BEFORE THIS STUDY: Almost seven in ten people who recover from an episode of low back pain will experience a recurrence within the following year. Evidence suggests that exercise alone or combined with education reduces the risk of recurrence; however, many investigated exercises require specialised equipment and close supervision and can incur high costs. Accessible and affordable forms of exercise that enable individuals to self-manage their back pain have not been evaluated as interventions to prevent low back pain recurrence. In 2022, we published a systematic review examining walking, cycling, and swimming to treat and prevent low back pain. We searched Medline, Embase, CINAHL, PEDro, and CENTRAL databases for peer-reviewed, randomised controlled trials from database inception until April 14, 2021, with no language restrictions. The search strategy was based on the recommended search terms of the Cochrane Back and Neck Group for "randomised controlled trials" and "low back pain", combined with search terms for walking, cycling, and swimming. We identified no trials that assessed the effectiveness of these exercises for preventing recurrences of low back pain. Walking is an accessible and low-cost exercise that reduces pain and disability in chronic low back pain; however, its effectiveness and costeffectiveness in preventing recurrences have not been explored. ADDED VALUE OF THIS STUDY: To our knowledge, WalkBack is a world-first trial, demonstrating that a walking and education intervention, compared with a no treatment control, can substantially reduce recurrences of low back pain. The total number of adverse events was similar across groups; however, the intervention group reported twice as many lower extremity injuries than were observed in the control group. The intervention also had a high probability of being cost-effective compared with a no treatment control. IMPLICATIONS OF ALL THE AVAILABLE EVIDENCE: This walking and education intervention, delivered using a health coaching approach, significantly reduced the recurrence of low back pain. Being accessible and low cost, this intervention has a better potential of being successfully implemented at scale than previously investigated forms of exercise. These results indicate the importance of preventive management and could affect how low back pain is managed. |
| Abstract: | BACKGROUND: Recurrence of low back pain is common and a substantial contributor to the disease and economic burden of low back pain. Exercise is recommended to prevent recurrence, but the effectiveness and cost-effectiveness of an accessible and low-cost intervention, such as walking, is yet to be established. We aimed to investigate the clinical effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention to prevent the recurrence of low back pain. METHODS: WalkBack was a two-armed, randomised controlled trial, which recruited adults (aged 18 years or older) from across Australia who had recently recovered from an episode of non-specific low back pain that was not attributed to a specific diagnosis, and which lasted for at least 24 h. Participants were randomly assigned to an individualised, progressive walking and education intervention facilitated by six sessions with a physiotherapist across 6 months or to a no treatment control group (1:1). The randomisation schedule comprised randomly permuted blocks of 4, 6, and 8 and was stratified by history of more than two previous episodes of low back pain and referral method. Physiotherapists and participants were not masked to allocation. Participants were followed for a minimum of 12 months and a maximum of 36 months, depending on the date of enrolment. The primary outcome was days to the first recurrence of an activity-limiting episode of low back pain, collected in the intention-to-treat population via monthly self-report. Cost-effectiveness was evaluated from the societal perspective and expressed as incremental cost per quality-adjusted life-year (QALY) gained. The trial was prospectively registered (ACTRN12619001134112). FINDINGS: Between Sept 23, 2019, and June 10, 2022, 3,206 potential participants were screened for eligibility, 2,505 (78%) were excluded, and 701 were randomly assigned (351 to the intervention group and 350 to the no treatment control group). Most participants were female (565 (81%) of 701) and the mean age of participants was 54 years (SD 12). The intervention was effective in preventing an episode of activity-limiting low back pain (hazard ratio 0.72 (95% CI 0.60 to 0.85), p = 0.0002). The median days to a recurrence was 208 days (95% CI 149 to 295) in the intervention group and 112 days (89 to 140) in the control group. The incremental cost per QALY gained was AU$7,802, giving a 94% probability that the intervention was cost-effective at a willingness-to-pay threshold of $28,000. Although the total number of participants experiencing at least one adverse event over 12 months was similar between the intervention and control groups (183 (52%) of 351 and 190 (54%) of 350, respectively, p = 0.60), there was a greater number of adverse events related to the lower extremities in the intervention group than in the control group (100 in the intervention group and 54 in the control group). INTERPRETATION: An individualised, progressive walking and education intervention significantly reduced low back pain recurrence. This accessible, scalable, and safe intervention could affect how low back pain is managed. FUNDING: National Health and Medical Research Council, Australia. Full text (sometimes free) may be available at these link(s):  help |
