Walking Program for Low Back Pain

Welcome back to Spine IQ’s Back Blog! Last week we discussed how to incorporate group exercise for older adults into your clinical practice. This week we are focused on how to incorporate a walking program for patients with low back pain. Of clinical interest is a recent systematic review and meta-analysis which found that walking programs were just as effective in reducing pain and disability as supervised exercise for patients with low back pain (1). This suggests that walking programs are another potential tool in the spine clinician’s toolbox to help patients with low back pain. Below we summarize walking programs described in the literature that can be incorporated in your office. Such programs can serve as either a patient self-management tool or a staff guided activity. With self-management, you provide information to that patient about how to begin a walking program independently that is based on your concerns about their health. There are generally no costs to the patients associated with this approach. Staff-guided walking programs can be made available to your patients for a fee, with the added benefit of increased compliance, monitored outcomes and perhaps even more fun!

Intensity:

The Borg Breathlessness Scale and the Talk Test Scale are two validated measures to evaluate exercise intensity, even for beginners. It is recommended that patients with low back pain walk at or slightly above a moderate level of intensity as described and highlighted in the scales below (2):

Borg Breathlessness Scale (3):

0	No breathlessness at all
0.5	Very, very slight (just noticeable)
1	Very slight
2	Slight breathlessness
3*	Moderate*
4*	Somewhat severe*
5	Severe breathlessness
6
7	Very severe breathlessness
8
9	Very, very severe (almost maximal)
10	Maximal

Talk test scale (4):

 

1	Very light activity Breathing not changed
2-3	Light activity Easy to breathe and carry a conversation
4-6*	Moderate activity Breathing more heavily – can carry on a conversation with more effort*
7-8	Vigorous activity On the verge on becoming uncomfortable – conversation requires maximum effort
9	Very hard activity Difficult to maintain exercise or speak
10	Maximum effort activity Full out effort – no conversation

** Note: If one of your patients exhibits labored breathing in the Breathlessness or Talk test  be certain to refer those patients for evaluation of additional underlying conditions.

 Walking programs:

Several walking programs have been validated and are available for use (1). If you are looking for something that can be implemented immediately, consider the following templates. They are based on current research and the recommendations of the American Heart Association. Using these as a starting point allows you to immediately implement them in your office with the ability to modify based on patient preference and needs.

Template walking program:

Intervention	Description
Joint mobility	Time: 5 minutes 8-12 rotations of the neck, shoulder, hip and ankle 8-12 flexion-extension of the knee, wrist, elbow and hips
Brisk walking	Time: 15 minutes Intensity: Borg Scale 3-4; Talk test 4-6
Strengthening and/or stretching	Time: 5 minutes 8-12 flexion-extension of arms against a wall (modified pushups) 8-12 bringing knees to chest in a standing position 8-12 touch your toes while standing
Brisk walking	Time: 20 minutes Intensity: Borg Scale 3-4; Talk test 4-6
Cool-down walk	Time: 5 minutes Intensity: Borg Scale 0.5 – 2; Talk test 1-3

American Heart Association walking program summary:

 

	Monday	Tuesday	Wednesday	Thursday	Friday	Weekend
Week 1	Easy walk: 5-10 min Stretch: 2 min Easy walk 5-10 min	Easy walk: 10-15 min	Easy walk: 5-10 min Stretch: 2 min Easy walk: 5-10 min	Easy walk: 10-15 min	Rest	Easy walk: 15-20 min
Week 3	Easy walk: 10-15 min Stretch: 2 min Brisk walk: 5-10 min	Easy walk: 15-20 min Stretch: 2 min	Easy walk: 10-15 min Stretch: 2 min Brisk walk: 5-10 min	Easy walk: 15-20 min Stretch: 2 min	Rest	Easy walk: 15-20 min
Week 6	Total time: 24-34 min Easy walk: 15-20 min Power intervals: Power walk: 30 secs Easy walk: 1 min Repeat 4-6 times Easy walk 3-5 min	Alternate activity of your choice for 20-30 minutes	Easy walk: 30-35 min Stretch 2 mins	Easy walk: 25-30 min Stretch: 2 min	Rest	Easy walk: 25-35 min

 

Conclusion:

Walking programs are a low cost or no-cost, evidence-based intervention depending on patient preference and/or your utilization process. The templates outlined above provide a personalized way to accommodate patient needs and preferences, while also establishing you as a community leader in promoting health activities.

 

Stay tuned for next week when we dive into exercise and neck pain!

References:

1. Vanti C, Andreatta S, Borghi S, Guccione AA, Pillastrini P, Bertozzi L. The effectiveness of walking versus exercise on pain and function in chronic low back pain: a systematic review and meta-analysis of randomized trials. Disabil Rehabil. 2019 Mar;41(6):622–32.
2. Eadie J, van de Water AT, Lonsdale C, Tully MA, van Mechelen W, Boreham CA, et al. Physiotherapy for sleep disturbance in people with chronic low back pain: results of a feasibility randomized controlled trial. Arch Phys Med Rehabil. 2013 Nov;94(11):2083–92.
3. Kendrick KR, Baxi SC, Smith RM. Usefulness of the modified 0-10 Borg scale in assessing the degree of dyspnea in patients with COPD and asthma. J Emerg Nurs. 2000 Jun;26(3):216–22.
4. Measuring Physical Activity Intensity | Physical Activity | CDC [Internet]. 2020 [cited 2021 Jun 10]. Available from: https://www.cdc.gov/physicalactivity/basics/measuring/index.html