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- Chronic low back pain
- Walking activity
- Strength training
- Randomised control trial

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The study took place at an outpatient clinic in Lod, Israel.

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Participants  were recruited from the Department of Physiotherapy at Maccabi Healthcare Services in Lod, Israel.

Inclusion criteria were as follows:

Male / female

Ages 18-65

With chronic lower back pain.

Individuals who were post surgery or trauma, involved in road accidents, had cardiovascular disease and with oncological disease were excluded.

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Random assignment of participants to either the aerobic walking or muscle strengthening group.

Assignment was concealed to all except patients themselves and a third party researcher with no involvement.

Patients trained twice a week for six weeks. Session duration increased incrementally each week until week 5.

The walking group walked on treadmills. Sessions consisted of a 5-minute warm  up, followed by intense walking, and concluded with a 5-minute cool down.

The exercise group engaged in strengthening exercises for the trunk and limbs. Patients performed low-load exercise and gradually progressed to higher loads. Load was increased by a greater number of repetitions and changing positions from lying (low load) to kneeling (high load).

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2 physical therapists administered pre- and post- treatment assessment.

Both these therapists and the researcher who conducted the data analysis were all blinded.

A walking test examined the distance patients could walk within 6 minutes.

The trunk flexor endurance test assessed muscular endurance of the deep core muscles. The time during which the position could be sustained was measured.

Comparisons between groups were conducted using analysis of a covariate, being baseline measurements.

Changes within groups were evaluated using a paired Student's t-test, with a significance level of P<0.05.

The 'Sorensen Back Extension Test' (Moreau, Green, Johnson & Moreau, 2001), the 'Owestry Low Back Pain Disability Questionnaire' (Yates and Shastri-Hurst, 2017), the 'Fear Avoidance Beliefs Questionnaire' (Waddell, Newton, Henderson, Somerville & Main, 1993) and the 'Back Pain Functional Scale' (Sánchez-Zuriaga, López-Pascual, Garrido-Jaén, de Moya & Prat-Pastor, 2011) were also used.

The 'Kolmogorav-Smirnov Test' (Drezner, Turel & Zerom, 2010) checked for normality.

Data was analyses using the Statistical Package for Social Sciences.

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P: 52 patients whereof 9  withdrew after randomisation. The sample consisted of males (n=11) and females (n=15) between 18-65 years, who had  chronic low back pain for 3 or more months with or without radiation to the lower limb. They were sedentary patients, who were neither post surgery or trauma, and did not have cardiovascular or oncological issues at baseline.

I: Walking training with moderate intensity treadmill walking sessions twice a week for six weeks.

C: Exercise sessions consisting of lower back exercises twice a week for six weeks.

O: The primary outcome was walking distance, assessed by a 6-minute walk test. Patients were required to walk as long a distance as possible in 6 minutes. Other outcomes included trunk flexor and trunk extension endurance, Oswestry Low Back Pain Disability Questionnaire, Fear-Avoidance Beliefs Questionnaire, and functional status measured through a test based on Low Back Pain Functional Scale (LBPFS) and the 36-item Short-Form Health Survey Questionnaire (SF-36).

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7.1. Graph and Tables  for results section

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7.1. Graph and Tables  for results section

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Table 1
Table 2
Figure 2

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In relation to the 6-minute walking test, the mean distance travelled in the walking group increased by 70.7 metres (95% confidence interval 12.3-119.7) and by 43.8 metres in the exercise group (95% CI 19.6-68.0).

The Trunk Flexor Endurance Test highlighted an increase by a mean of 0.6  (95% CI 0.0–1.1) in the waling group and by 1.1 (95% CI 0.3–1.8) in the exercise group.

Although differences were noted within groups, there was an insignificant difference between the two groups for each of the two assessments outlined above.

6 patients from the intervention group and 3 from the control withdrew from the study. The Low Back Pain Functional Scale results were substantially higher among those who withdrew compared to participants who completed treatment (57.9±8.0 points vs. 49.4±8.7, respectively). This indicated a better outcome for persons who withdrew.

Results from the Oswestry Disability Questionnaire were also significantly lower among those who withdrew (21.3±9), once again emphasising better results for individuals who did not partake in either intervention.

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It was hypothesised that muscle strengthening would be the most effective treatment.

Differences between the groups were statistically insignificant. In fact, it was noted that both groups had equal levels of effectiveness. Thus, the hypothesis was not supported.

Participants were recruited from only one medical institution throughout the city, giving rise to potential bias, as patients within that facility may have similar characteristics which can affect results.

This factor, along with a  small sample size, hinder on the internal and external validity of the experiment.

Findings lack meaningful implications for healthcare and clinical significance as no significant difference between groups was detected.

The only substance that can be derived from this study is that both treatments may be used in unison to produce better results..

Shnayderman and Michal Katz-Leurer (2012) should be interpreted with  caution, as results may be inaccurate in the long term. Administering treatments for a greater duration may be beneficial and produce meaningful results.

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Shnayderman and Michal Katz-Leurer (2012) failed to record the clinical parameters of the patients at baseline, which could have helped us see the differences in the outcomes after the intervention.

Although it is difficult to blind the patients, the non-blinding of subjects can have implications of bias for the study. A placebo effect might show, for example, the belief of doing exercise helps per se can affect the patients' performance in the walking test. However, the placebo effect can be present in both the intervention and control group.

Concerning compliance, we do not know whatever the patients exercise beside the treatments, e.g. the walking group may start doing strength exercise beside the intervention as well.

Of the 52 participants  allocated into groups, 9 individuals withdrew from he study, meaning 43 remained. These 43 participants were assessed for the 6-minute walking test. This comprised 82.7% of total initial participants, which is below the 85% threshold. Hence, Shnayderman and Michal Katz-Leurer (2012) was unsatisfactory in this aspect.

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Drezner, Z., Turel, O., & Zerom, D. (2010). A Modified Kolmogorov–Smirnov Test for Normality. Communications In Statistics - Simulation And Computation, 39(4), 693-704. doi: 10.1080/03610911003615816

Moreau, C., Green, B., Johnson, C., & Moreau, S. (2001). Isometric Back Extension Endurance Tests: A Review of the Literature. Journal Of Manipulative And Physiological Therapeutics, 24(2), 110-122. doi: 10.1067/mmt.2001.112563

Sánchez-Zuriaga, P., López-Pascual, P., Garrido-Jaén, P., De Moya, P., & Prat-Pastor, P. (2011). Reliability and Validity of a New Objective Tool for Low Back Pain Functional Assessment. Spine, 36(16), 1279–1288.

Verhagen AP et al (1998). The Delphi list: a criteria list for quality assessment of randomised clinical trials for conducting systematic reviews developed by Delphi consensus. Journal of Clinical Epidemiology, 51(12):1235-41).

Waddell, G., Newton, M., Henderson, I., Somerville, D., & Main, C. (1993). A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain, 52(2), 157-168. doi: 10.1016/0304-3959(93)90127-b

Yates, M., & Shastri-Hurst, N. (2017). The Oswestry Disability Index. Occupational Medicine, 67(3), 241–242.

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Figure 2: A depiction of the trunk flexor endurance test.