- Top of page
- PATIENTS AND METHODS
- AUTHOR CONTRIBUTIONS
Exercise is a common treatment for individuals with chronic low back or neck pain and is used to improve physical function and decrease symptoms (e.g., pain, stiffness). Exercise has also been used to minimize disability by decreasing individuals' fears about pain during movement and by reshaping their attitudes and beliefs about their pain. The latter goal is common in cognitive behavioral and functional restoration programs, both of which typically use a quota-based, nonpain-contingent approach to exercise (1).
In the past decade, a number of randomized trials, systematic reviews, and clinical practice guidelines have supported the use of exercise for the treatment of chronic low back pain (2–14) and chronic neck pain (15–19). Although there is still much to learn about the types and intensity of exercises that are most effective, recent meta-analyses by Hayden and colleagues suggest that individually tailored, supervised exercise programs that include stretching and strengthening are associated with the best outcomes for individuals with chronic low back pain (5, 6). Hayden et al also found that exercise in combination with other conservative treatments and high-dose exercise, defined as an exercise intervention with a total time of 20 hours or more, improved pain and function more than exercise alone or low-dose exercise (6).
The findings for chronic neck pain are similar, although somewhat less definitive, with data suggesting that certain types of exercise are most effective and that supervised exercise is more effective than nonsupervised exercise. According to evidence statements on the treatment of chronic neck pain published by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain (19), supervised and home exercise plus advice is marginally more effective than advice alone for chronic whiplash-associated disorders; a neck exercise program alone or in combination with spinal manipulation is more effective than spinal manipulation alone, transcutaneous electrical nerve stimulation, or usual care for chronic, nonspecific neck pain; and both endurance (repetitive submaximal resistance exercises) and strengthening exercises (repetitive maximal resistance exercises) are effective treatments for chronic, nonspecific neck pain. Data also suggest that aerobic exercise and stretching alone are less effective than endurance and strengthening exercises (20, 21), and that stretching exercises for the neck are as effective as manual therapy (22). Evidence on the additive effect of other conservative treatments in combination with exercise for the treatment of chronic neck pain is less clear. There are some data to suggest that multimodal approaches that include exercise may be more effective than single-treatment approaches (23, 24).
Although the past decade has led to gains in our understanding of the efficacy of exercise for chronic low back and neck pain, less is known about exercise prescription in routine clinical practice. Who is prescribing it? Who is getting it? What is being prescribed? Such information would be useful in assessing the translation of research findings to clinical practice and in identifying areas to target for increased promotion of exercise as an effective treatment.
We analyzed data from a population-based survey of health care provider and treatment use by individuals with chronic low back or neck pain in order to gain a better understanding of the use of exercise in the treatment of these conditions. Our specific objectives were 1) to determine the extent to which exercise is prescribed by physicians, physical therapists (PTs), and chiropractors for the treatment of chronic low back and neck pain; 2) to identify demographic, insurance, work, and health-related characteristics associated with exercise prescription; 3) to describe the amount of supervision provided and types of exercises prescribed for each provider type; and 4) to determine the extent to which other conservative treatments are used in combination with exercise.
- Top of page
- PATIENTS AND METHODS
- AUTHOR CONTRIBUTIONS
Exercise was prescribed to 48% of subjects who had seen a physician, PT, and/or chiropractor in the past year. Of those who were prescribed exercise, 46.0% received the prescription from a PT, 28.6% from a physician, 20.9% from a chiropractor, and 4.6% from other (more than one provider or not specified).
Descriptive data on exercise prescription by provider type, conditional on seeing the provider, are presented in Table 1. Of those who saw a PT, 63.8% were prescribed exercise, of those who saw a chiropractor, 33.1% were prescribed exercise, and of those who saw a physician, 14.4% were prescribed exercise. When we stratified our analyses by location (i.e., back or neck), the percentages were similar and not statistically different.
Table 1. Exercise prescription by provider type*
|Provider type||Seen in past year||Prescribed exercise†|
|Physician||94.4 (92.0–96.1)||14.4 (11.6–17.7)|
|Physical therapist||34.2 (30.4–38.3)||63.8 (56.7–70.3)|
|Chiropractor||30.0 (26.1–34.1)||33.1 (26.0–41.2)|
|Physician, physical therapist, and/or chiropractor||100||47.5 (43.3–51.8)|
Although most subjects in the sample saw a physician, only 14.4% were prescribed exercise. Some individuals who saw a physician and were not prescribed exercise saw a PT who did. Of those subjects who saw a physician and did not receive exercise instruction, 26.3% saw a PT who did prescribe exercise and 9.7% saw a chiropractor who did prescribe exercise.
The demographic, insurance, work-related, and health-related characteristics of the sample by exercise prescription are presented in Table 2. In bivariate comparisons, individuals who were female, more educated, on worker's compensation, employed in the past year, had seen a PT, or had seen a chiropractor were more likely to receive exercise prescription. The number of patient visits also increased the likelihood of exercise prescription by chiropractors. Individuals who were on Medicare, who reported poorer general health, or who reported greater physical disability were less likely to be prescribed exercise. Variables that approached significance and were associated with an increased likelihood of exercise prescription were younger age, private insurance, not receiving narcotics, and more physical therapy visits.
Table 2. Demographic and clinical characteristics by exercise prescription (n = 684)*
|No (n = 361)||Yes (n = 323)|
| Mean age, years||53.4||51.6||0.15|
| Female sex||57.7||66.5||0.04|
| Race|| || || |
| Non-Hispanic white||73.5||73.3|| |
| Non-Hispanic African American||16.9||16.4||0.31|
| Non-Hispanic other||6.5||4.2|| |
| Hispanic||3.2||6.1|| |
| Less than high school||20.4||12.7|| |
| High school||33.4||24.2||< 0.001|
| More than high school||46.2||63.2|| |
|Insurance and work-related Insurance†|
| Medicare and age ≥62 years||21.8||17.7||0.23|
| Worker's compensation||4.9||11.5||0.003|
| Disability or Medicare and age <62 years||27.7||21.4||0.10|
| Employed in past year||18.2||26.7||< 0.001|
| Pain location|| || || |
| Neck||15.3||18.5|| |
| Mean duration of problem, years‡||9.6||9.0||0.57|
| Fair or poor general health||44.8||34.0||0.01|
| Mean SF-12 PCS score||30.2||32.7||0.005|
| Mean SF-12 MCS score||48.0||47.9||0.95|
| Mean Roland-Morris score§||16.2||14.6||0.008|
| Mean Neck Disability Index score¶||33.1||32.0||0.72|
| Mean pain rating past 3 months (range 0–10)||6.8||6.6||0.26|
| Have extremity pain||69.9||72.9||0.45|
| Have extremity weakness||57.4||56.3||0.81|
| Receiving narcotics for back or neck pain||60.2||52.3||0.07|
| Had spinal surgery in past year||7.5||9.0||0.52|
|Providers seen in past year|
| Mean physician visits#||9.2||9.7||0.73|
| Physical therapist||12.5||58.2||< 0.001|
| Mean physical therapist visits#||12.7||17.9||0.11|
| Chiropractor||18.2||43.0||< 0.001|
| Mean chiropractor visits#||16.2||27.4||0.02|
The results of the multivariable logistic regression analyses are presented in Table 3. In model 1, being female, more educated, receiving worker's compensation, receiving Medicaid, or being employed in the past year increased the likelihood of receiving exercise prescription. Location of pain (back or neck) was not related to exercise prescription. When provider use variables were added (model 2), being female, more educated, or receiving worker's compensation continued to increase the likelihood of exercise prescription. The type of provider seen in the past year was the strongest predictor of exercise prescription. None of the health-related variables were associated with exercise prescription.
Table 3. Multivariable logistic regression analysis of patient-level characteristics associated with exercise prescription*
|Characteristic||Model 1||Model 2|
|OR (95% CI)||P||OR (95% CI)||P|
| Age||0.99 (0.97–1.01)||0.477||0.99 (0.96–1.01)||0.240|
| Female||1.80 (1.20–2.71)||0.005||2.04 (1.26–3.28)||0.004|
| White||1.26 (0.82–1.94)||0.297||1.38 (0.82–2.33)||0.226|
| More than high school education||1.83 (1.24–2.69)||0.002||1.85 (1.19–2.88)||0.007|
|Insurance and work-related|
| Private insurance||1.54 (0.83–2.87)||0.174||1.50 (0.65–3.46)||0.341|
| Medicare||1.37 (0.67–2.81)||0.394||1.66 (0.73–3.81)||0.228|
| Medicaid||2.33 (1.21–4.48)||0.011||1.84 (0.82–4.13)||0.139|
| Worker's compensation||2.55 (1.24–5.25)||0.011||2.39 (1.23–4.67)||0.011|
| Disability insurance||1.16 (0.66–2.03)||0.607||1.58 (0.84–2.99)||0.159|
| No insurance||1.21 (0.53–2.79)||0.654||1.71 (0.61–4.83)||0.310|
| Employed in the past year||1.89 (1.18–3.03)||0.008||1.63 (0.96–2.76)||0.068|
| SF-12 PCS score||1.02 (1.00–1.05)||0.071||1.01 (0.99–1.04)||0.366|
| SF-12 MCS score||1.00 (0.98–1.02)||0.753||1.00 (0.98–1.02)||0.703|
| Extremity pain||1.35 (0.87–2.10)||0.183||0.99 (0.61–1.63)||0.983|
| Extremity weakness||1.27 (0.83–1.94)||0.271||1.25 (0.77–2.03)||0.364|
| Pain intensity||1.00 (0.91–1.11)||0.951||1.02 (0.91–1.13)||0.778|
| Prescribed narcotics||0.81 (0.54–1.20)||0.294||0.70 (0.44–1.13)||0.141|
| Surgery in past year||1.12 (0.57–2.20)||0.751||0.67 (0.29–1.55)||0.350|
| Back pain||1.09 (0.65–1.82)||0.753||1.39 (0.73–2.62)||0.313|
|Providers seen|| || || || |
| Physician|| || ||2.01 (0.76–5.31)||0.161|
| Physical therapist|| || ||11.96 (7.15–20.01)||< 0.001|
| Chiropractor|| || ||4.40 (2.55–7.57)||< 0.001|
There were some differences in the amount of supervision and types of exercises prescribed by the different providers (Table 4). PTs were more likely to provide supervision than physicians and chiropractors. PTs were also more likely than physicians to prescribe stretching. Findings that approached significance included PTs being more likely to prescribe strengthening exercises and less likely to prescribe walking. There were few differences among providers in regard to duration of exercise, with the exception of PTs prescribing walking for a shorter and stretching for a longer duration. There were no differences in exercise frequency (generally 5 times per week). The total exercise time per week also did not vary by provider and was ∼3.5 hours per week.
Table 4. Exercise characteristics by providers who prescribed exercise (n = 684)*
|Exercise characteristic||PT||MD||DC||Significant differences†|
|Provided supervision, %||65.5||29.3||28.6||PT > MD, DC (P < 0.001)|
|Type of exercise, %|
| Walking||52.2||70.1||50.8||PT < MD (P = 0.09)|
| Stretching||92.2||75.6||87.3||PT > MD (P = 0.003)|
| Strengthening||70.1||56.4||55.8||PT > MD (P = 0.05)|
| || || || ||PT > DC (P = 0.08)|
| Range of motion||81.2||71.7||76.4||NS|
|Mean duration, minutes/session|
| Walking||20.6||27.4||28.1||PT < MD (P = 0.02)|
| || || || ||PT < DC (P = 0.08)|
| Stretching||15.8||10.3||11.6||PT > MD (P = 0.003)|
| || || || ||PT > DC (P = 0.04)|
| Range of motion||13.5||10.7||10.9||NS|
|Mean frequency, times/week|
| Range of motion||4.8||5.5||5.9||NS|
|Mean total minutes of exercise/week||266||228||210||NS|
Of those prescribed exercise, 86% used ≥1 additional conservative physical treatments, with a mean of 3 treatments per patient (Table 5). Heat, cold, and electrical stimulation were the most common additional treatments for subjects with back pain, whereas heat, cold, and manipulation were most common for subjects with neck pain. Medication use was also quite high in those prescribed exercise.
Table 5. Use of other physical treatments and medications by those prescribed exercise (n = 684)*
| Heat||55.5 (48.9–62.1)||73.2 (59.4–86.9)|
| Cold||53.0 (46.6–59.5)||52.5 (36.1–68.9)|
| Electrical stimulation||34.9 (28.7–41.2)||40.1 (23.8–56.3)|
| Manipulation||32.1 (25.8–38.4)||48.9 (34.1–63.8)|
| Massage||26.7 (20.7–32.6)||37.2 (21.4–53.0)|
| TENS||25.1 (19.3–31.0)||34.6 (18.7–50.5)|
| Ultrasound||24.1 (18.4–29.8)||39.2 (23.2–55.3)|
| Acupuncture||10.6 (6.3–14.9)||2.3 (0.0–5.5)|
| Traction||9.0 (5.0–13.0)||22.6 (8.2–36.9)|
| OTC pain medications||96.9 (94.7–99.1)||95.7 (88.8–102.5)|
| Narcotics||55.5 (48.8–62.2)||37.0 (21.2–52.8)|
| Prescription NSAIDs||43.9 (37.3–50.6)||32.9 (18.3–47.4)|
| Muscle relaxants||31.5 (25.2–37.7)||31.3 (16.6–46.0)|
| Antidepressants||31.5 (25.2–37.8)||27.5 (13.4–41.5)|
| TCA/anticonvulsant||21.3 (15.7–26.8)||6.0 (0.00–12.8)|
- Top of page
- PATIENTS AND METHODS
- AUTHOR CONTRIBUTIONS
Less than 50% of the subjects in our sample were prescribed exercise, one of the few moderately effective therapies for the highly disabling illness of chronic back and neck pain. Type of provider seen played a major role in whether individuals received exercise prescription, and was more influential than any of the other patient-related factors. These findings agree with other studies on the care of back pain that have found that “who you see is what you get” (37, 38).
As might be expected, PTs were the most likely to prescribe exercise; however, approximately one-third of individuals who saw a PT did not receive exercise prescription. Chiropractors were the next most likely to prescribe exercise and were more likely to do so if they saw the patient more often. Although physicians were the least likely to prescribe exercise, some patients who saw a physician were prescribed exercise by a PT or chiropractor. Patients who saw a PT were likely referred by a physician. Patients who saw a chiropractor may have had a physician referral for chiropractic care, but this is not common (39). Still, less than half of the subjects who saw a physician were prescribed exercise by any provider. Considering current evidence of the efficacy of exercise, these findings demonstrate that exercise is being underutilized as a treatment for chronic back and neck pain.
In bivariate analyses, individuals with poorer measures of health and function were less likely to receive exercise prescription. However, in multivariate analyses, this relationship was not maintained. Contrary to what we hypothesized, none of the health-related characteristics predicted whether an individual was prescribed exercise. Although there are some data to suggest that individuals with different degrees of impairment respond more or less favorably to exercise (33, 34, 40–44), providers' decisions to prescribe exercise did not appear to be influenced by the degree of impairment. Our findings disagree with the literature on factors associated with physician advice to exercise as a preventive intervention. Several studies have found that, in the general population, individuals with poorer health status were more likely to receive physician advice to exercise (45–47).
We also found that women, people with a higher education level, and those receiving worker's compensation were more likely to be prescribed exercise, controlling for other demographic and health-related characteristics and provider type. Other studies have found a positive association between physician prescription of physical activity and female sex and education level (45, 48). Studies also suggest that women and more educated individuals are more likely to be active participants in their care, which in turn affects the way the provider interacts with the patient and ultimately leads to more commitment to treatment regimens (49, 50). Our findings regarding worker's compensation seem reasonable, because individuals receiving worker's compensation are frequently physical laborers who were injured on the job and are being treated with the goal of returning to work.
For those who were prescribed exercise, the type of provider seen determined the amount of supervision received and, to some extent, the types of exercises prescribed. PTs were much more likely to provide supervision and were more likely to prescribe stretching and strengthening exercises. Current systematic reviews and practice guidelines for the treatment of chronic low back pain and neck pain suggest that exercise supervision and the inclusion of strengthening exercises lead to better outcomes (5, 6, 19). For chronic low back pain, stretching exercises have also been included in recommendations (5, 6). In addition, there is evidence to support the combination of treatments and/or multimodal approaches to care (6, 23, 24). Most of the subjects in the study were using a combination of conservative treatments, with varying levels of evidence to support their use (3, 51).
There was a tendency toward physicians being more likely than PTs to prescribe walking and less likely to prescribe strengthening exercises. This finding may be related to time constraints on and/or the comfort level of the physician. Instructions on walking can be given fairly quickly, with little explanation, and with no need for demonstration or performance by the patient.
All types of providers appeared to provide therapeutic levels of exercise duration, with patients instructed to exercise for a total of ∼3.5 hours a week. Following these guidelines for 6 weeks would achieve the high-dosage rate of 20 hours that has been recommended for the treatment of chronic low back pain (6).
This study had some limitations, the most significant being that we relied on patient self-report regarding exercise prescription, type, frequency, and duration. Responses to the questions may have been subject to social desirability bias. In the debriefing of pilot respondents during instrument pretesting, understanding of the exercise questions was good. A few subjects were unclear on what was meant by range of motion exercises. Nonetheless, we are unable to verify the accuracy with which subjects categorized their exercises and recalled instructions on duration and frequency. More importantly, we have no data on the duration that they actually exercised. There may also have been issues with subject recall (i.e., not remembering that they were prescribed exercise). Although not specific to the exercise questions, we did conduct a pilot study to assess how well individuals recalled their number of provider visits in the past year. When compared with chart abstraction, the correlation between the 2 measures of visit number was 0.83.
We believe that our population-based study provides valuable information that is currently lacking in the literature regarding exercise prescription in everyday practice. Our findings suggest that exercise is being underutilized as a treatment for chronic back and neck pain and, to some extent, that the amount of supervision and types of exercises prescribed do not follow current practice guidelines. Although exercise prescription provided by PTs appears to be the most in line with current guidelines, there is much room for improvement by all types of providers who prescribe exercise for patients with chronic back and neck pain.
Future research should utilize other research designs (e.g., cohort) and sources of data (e.g., provider report, claims data) to gather information regarding exercise prescription. It should also further explore provider-level characteristics and additional patient-level characteristics associated with exercise prescription, as well as barriers to prescription of and adherence to exercise treatments. Barriers to exercise prescription may include practitioner knowledge, organizational aspects of the practice, and relatively poor reimbursement for exercise instruction compared with other modes of back and neck treatment. Patient-provider collaborative models of care, provider-provider collaborative models of care, and provider training models should also be explored to determine models that are most effective in facilitating the initiation of and compliance with an exercise program.
- Top of page
- PATIENTS AND METHODS
- AUTHOR CONTRIBUTIONS
Dr. Freburger had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study design. Freburger, Carey, Jackman.
Acquisition of data. Carey, Jackman.
Analysis and interpretation of data. Freburger, Carey, Holmes, Wallace, Castel, Darter, Jackman.
Manuscript preparation. Freburger, Carey, Holmes, Wallace, Castel.
Statistical analysis. Freburger, Holmes.