# data[].attributes.body
Aleks Trajkovski SID: 460494920
Gracey van Beek SID: 470388224
Olivia Hall SID: 470447521
Teresa Lail-Tran SID: 450113518

# data[].attributes.body
Citation: Shnayderman, I., & Katz-Leurer, M. (2013). An aerobic walking programme versus muscle strengthening programme for chronic low back pain: a randomized controlled trial. Clinical Rehabilitation, 27(3), 207-214.

Keywords: Chronic low back pain, walking activity, strength training, randomised control trial.

Study Design: A randomised control clinical trial with blind assessors.

Study Setting: An outpatient clinic

# data[].attributes.body
Patient: The targeted population was 52 sedentary people, 26 for each group, recruited from the Department of Physiotherapy, Maccabi Healthcare Services in Lod, Israel. The inclusion criteria of people who were considered suitable for this study were males and/or females between the ages of 18-65 years, with chronic low back pain without radiation to the lower limb for 3 or more months.

The exclusion criteria includes patients who have had a fracture, surgery in the spinal or lower extremity and active cardiac disease as unstable angina/congestive heart failure/coronary arteries bypassed in the last six months. Also excluded are people receiving cancer treatment or suffering low back pain due to a road traffic accident.

# data[].attributes.body
Intervention: A walking group:

Moderate intense treadmill walking, twice a week for six weeks. In the first week, these sessions were 20 minutes long, and increased 5 minutes per week up to the fifth week. Each session went as followed:
1. 5 minute warm up at a self selected speed.
2. Intense walking.
3. 5 minute cool down at a self selected speed.

In the last four weeks, the patients exercised for 40 minutes each session at a low to moderate intensity. This intensity was based on patients resting heart rate which was calculated by the Karvonen formula that states for men: walking heart rate = ((220-age) - resting heart rate) x 50% + resting heart rate. For women: ((226-age) - resting heart rate) x 50% + resting heart rate.

# data[].attributes.body
Comparison: An exercise group:

Lower back, trunk, upper and lower limb active movements and strengthening exercises, twice a week for six weeks. In the first week, these sessions were 20 minutes long, and increased 5 minutes per week up to the fifth week. Each session went as followed:
1. 5 minute warm up of light exercise
2. Low load exercise, progressing through the duration of each exercise by increasing the number of exercise repetitions and by increasing loading positions
3. 5 minute cool down of light exercise.

# data[].attributes.body
Outcome: Six minute walking test:

The primary outcome parameter was a six minute walking test.

The six minute walking test saw each participant asked to cover as much distance as possible in six minutes. Their velocity indicated whether low back pain was affecting performance. Studies have shown 1.3 m/s is the average velocity seen in a healthy patient, 0.92 m/s for patients impacted by chronic low back pain.

# data[].attributes.body
The mean distance (m) covered by the walking group before the test was 431.8m (SD 95.1). After the test, the distance increased by 70.7 (95% confidence interval (CI) 12.3-127.7) to 502.5m (85.7). The distance covered by the exercise group in the pre-test was 441.0m (117.4). Post-test, 484.0m (120.3) was recorded, which was an increase of 43.0m (95% CI 19.6-68.0). There was no significant improvement between the walking and exercise group (no p-value provided). However, a significant improvement was found within both groups (no p-value provided).

# data[].attributes.body
The PEDro tool for RCT studies was chosen for this research based on the fact that the study is a randomised-controlled trial. The tool consists of 11 criteria which manage to assess 3 different risk areas of bias including: external validity (criteria 1), internal validity (criteria 2-9) and interpretability of the study (criteria 10-11). The tool does not directly state the cut-off score to determine the quality of the study leaving this down to interpreter discretion (PEDro Scale, 1999).

Overall, based on the results from the PEDro risk of bias tool, the study seems to be of a good quality in terms of external and internal validity as well as interpretability of statistics. Out of the 11 criteria of high quality research, the study met the requirements for 9, one criteria not being met due to a failure of researchers to blind subjects to their specific treatment, with this possibly resulting in performance bias. On top of this is the risk of attrition bias (attrition rate of 17.3%) due to a failure to receive key outcome data for at least 85% of participants. Both of these study weaknesses make us slightly sceptical of the outcomes and we recommend caution when interpreting results. .

PEDro Scale. (1999). Retrieved from https://www.pedro.org.au/wp-content/uploads/PEDro_scale.pdf

# data[].attributes.body
Ultimately, the study achieved its aims and supported the hypothesis as significant improvements were seen in participants within both the walking and aerobic exercise conditions. A statistically significant confidence interval of 95% suggests that frequent walking and exercise are beneficial for sedentary individuals with chronic back pain and the distance they can mobilize. There was no significant difference between either group in their effectiveness.

However, there were limitations in the way in which the study was conducted in terms of its internal validity. As suggested by the criteria 2-9 in the PEDro scale, two points were lost due to the lack of blinding of participants and a high drop out rate, measuring less than 85% of participants for key outcomes. Only 82.7% of individuals were tested by the six minute walking test following an intervention, and this suggests the study should be interpreted with caution. Although this significant attrition rate was compensated with an implementation of intention to treat, a larger sample size and a longer follow up was ultimately needed to determine further implications for clinical practice. Additionally, there is an evident risk of selection and performance bias through the way in which participants were educated on each study condition before involvement. This may have influenced their readiness to participate in the study to begin with, and dissuaded those with a fear of movement from involvement.
In contrast, external validity observed positive results in the outlining of eligibility criteria. Both groups consisted of subjects recruited from the Department of Physiology and did not differ significantly in a clinical or demographic sense. Individuals who were already physically active were excluded, as well as those with fractures in the spine or unstable cardiac disease.

Thus, both groups demonstrated sound confidence intervals, statistical validity and overall markable progress within each condition;  ultimately suggesting a potential for clinical significance. Although it provides a strong level of evidence for potential future treatment, limitations in its internal validity are evident, and the PEDro scale notes that a high score does not necessarily correlate to clinical usefulness. This is due to the fact that the scale does not take into account the validity of the evidence itself, the size of the treatment effect or any adverse effects that may outweigh positive ones.