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Here are four good reasons A Pilot Study of the Effects of High-Intensity Aerobic Exercise Versus Passive Interventions on Pain, Disability, Psychological Strain, and Serum Cortisol Concentrations in People With Chronic Low Back Pain Work-related musculoskeletal disorders among Brazilian dental students. Prevalence and correlates of musculoskeletal pain in Chinese elderly and the impact on 4-year physical function and quality of life. Is chronic non-specific low back pain chronic? Definitions of a problem and problems of a definition. Effects of exercise adherence on physical function among overweight older adults with knee osteoarthritis. The impact of migraine on quality of life in the general population Motor control or graded activity exercises for chronic low back pain? A randomised controlled trial Effect of physical exercise interventions on musculoskeletal pain in all body regions among office workers: a one-year randomized controlled trial. Individually tailored treatment targeting activity, motor behavior, and cognition reduces pain-related disability: a randomized controlled trial in patients with musculoskeletal pain. A controlled study of the effects of an early intervention on acute musculoskeletal pain problems Promoting physical activity in a socially and economically deprived community: a 12 month randomized control trial of fitness assessment and exercise consultation Self-Report Measures Best Explain Changes in Disability Compared With Physical Measures After Exercise Rehabilitation for Chronic Low Back Pain Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain Comparison of neuromuscular and quadriceps strengthening exercise in the treatment of varus malaligned knees with medial knee osteoarthritis: a randomised controlled trial protocol Effectiveness of manual therapies: the UK evidence report 'Physical activity at home (PAAH)', evaluation of a group versus home based physical activity program in community dwelling middle aged adults: rationale and study design A Randomized Clinical Trial of the Treatment Effects of Massage Compared to Relaxation Tape Recordings on Diffuse Long-Term Pain Effects of preferred-exercise prescription compared to usual exercise prescription on outcomes for people with non-specific low back pain: a randomized controlled trial [ACTRN12608000524392]
Study Design . A cross-sectional , descriptive vignette survey of practicing , musculoskeletal physical therapists . Objectives . The aim of this study was to determine if musculoskeletal physical therapists , in the United Kingdom , recognize when patients with low back pain ( LBP ) are at risk of chronicity due to psychosocial factors . A secondary aim was to explore the advice they give to patients about  work and activities .  Summary of Background Data . Psychosocial factors have been shown to be important in the progression from acute LBP to chronic disability . Early identification of individuals at risk of developing chronic disability is important to enable targeted intervention . Methods . Three vignettes were written based on acute LBP patients attending for physical therapy  and incorporated into a self-completed postal question naire sent to a simple r and om sample of musculoskeletal physical therapists in the United Kingdom ( n = 900 ) . After one reminder , 20 % of nonresponders were sent a further question naire ( n = 80 ) . Data were analyzed using the Statistical Package for the Social Sciences ( SPSS version 11 ) . Results . The response rate was 57.7 % ( n = 518 ) with 453 meeting all inclusion criteria . The sample consisted of physical therapists working in the musculoskeletal field across all practice setting s. Most correctly rated the chronicity risk of the low- and high-risk patient vignettes . Advice to restrict work and activity was common . Conclusions . Most physical therapists recognize when patients are at high risk of developing chronicity , yet many recommend the patient limit their activity levels and not work . Advice to “ not work ” is associated with more severe perceived spinal pathology , suggesting persistence of the biomedical model for LBP Background Knee osteoarthritis ( OA ) is one of the most common and costly chronic musculoskeletal conditions world-wide and is associated with substantial pain and disability . Many people with knee OA also experience co-morbidities that further add to the OA burden . Uptake of and adherence to physical activity recommendations is suboptimal in this patient population , leading to poorer OA outcomes and greater impact of associated co-morbidities . This pragmatic r and omised controlled trial will investigate the clinical - and cost-effectiveness of adding telephone coaching to a physiotherapist-delivered physical activity intervention for people with knee OA . Methods / Design 168 people with clinical ly diagnosed knee OA will be recruited from the community in metropolitan and regional areas and r and omly allocated to physiotherapy only , or physiotherapy plus nurse-delivered telephone coaching . Physiotherapy involves five treatment sessions over 6 months , incorporating a home exercise program of 4–6 exercises ( targeting knee extensor and hip abductor strength ) and advice to increase daily physical activity . Telephone coaching comprises 6–12 telephone calls over 6 months by health practitioners trained in applying the Health Change Australia ( HCA ) Model of Health Change to provide behaviour change support . The telephone coaching intervention aims to maximise adherence to the physiotherapy program , as well as facilitate increased levels of participation in general physical activity . The primary outcomes are pain measured by an 11-point numeric rating scale and self-reported physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale after 6 months . Secondary outcomes include physical activity levels , quality -of-life , and potential moderators and mediators of outcomes including self-efficacy , pain coping and depression . Relative cost-effectiveness will be determined from health service usage and outcome data . Follow-up assessment s will also occur at 12 and 18 months . Discussion The findings will help determine whether the addition of telephone coaching sessions can improve sustainability of outcomes from a physiotherapist-delivered physical activity intervention in people with knee OA.Trial Registration Australian New Zeal and Clinical Trials Registry reference : Chronic musculoskeletal pain constitutes a large socioeconomic challenge , and preventive measures with documented effects are warranted . The authors ' aim in this study was to prospect ively investigate the association between physical exercise , body mass index ( BMI ) , and risk of chronic pain in the low back and neck/shoulders . The study comprised data on approximately 30,000 women and men in the Nord-Trøndelag Health Study ( Norway ) who reported no pain or physical impairment at baseline in 1984 - 1986 . Occurrence of  chronic musculoskeletal pain  was assessed at follow-up in 1995 - 1997 . A generalized linear model was used to calculate adjusted risk ratios . For both females and males , hours of physical exercise per week were linearly and inversely associated with risk of chronic pain in the low back ( women : P-trend = 0.02 ; men : P-trend < 0.001 ) and neck/shoulders ( women : P-trend = 0.002 ; men : P-trend < 0.001 ) . Obese women and men had an approximately 20 % increased risk of chronic pain in both the low back and the neck/shoulders . Exercising for 1 or more hours per week compensated , to some extent , for the adverse effect of high BMI on risk of chronic pain . The authors conclude that physical inactivity and high BMI are associated with an increased risk of chronic pain in the low back and neck/shoulders in the general adult population Abstract Purpose : Important goals of cardiac rehabilitation maintenance programs ( CMP ) are to increase leisure time physical activity ( LTPA ) and improve health-related quality of life ( HRQoL ) . Elderly patients with cardiac disease and low exercise capacity are simultaneously the most severely affected and have the most to gain from exercise-based rehabilitation . Individualized combined exercise ( ICE ) may be an effective modality to achieve these goals . We compared six months of ICE to CMP in their effects on LTPA and HRQoL. Methods : Sixty patients ( 70 ± 9 years , 39 % female ) with cardiac disease and low exercise capacity ( < 6 MET ) were r and omly allocated to six months of once-weekly ICE or CMP . The patients in ICE performed moderate endurance and resistance exercise on machines , based on intensities from individual peak exercise testing . Patients in CMP performed weekly sessions of calisthenics , flexibility , coordination and relaxation activities . LTPA and HRQoL were assessed with accelerometry and question naires at baseline and six months . Results : Sixty patients completed the trial . ICE  increased vigorous PA ( ICE : Δ + 12 MET-min/d , CMP : Δ –5 MET-min/d , p = .02 ) and steps per day ( ICE : + 1586 steps/d , CMP : –838 steps/d , p < .01 ) compared to CMP after six months . ICE significantly improved in several components of HRQoL ( vitality , emotional health , social health , positive and negative affect ( all p < .05 ) compared to CMP . Conclusions : ICE result ed in significant improvements in physical activity levels and health related quality of life in moderate to high-risk patients compared to CMP . Implication s for rehabilitation Relatively low volumes and intensities of exercise may lead to substantial improvements in both physical activity levels and health-related quality of life Exercise modes in cardiac rehabilitation maintenance programs should not be limited to calisthenics and large group-based exercise Supplemental resistance exercise may improve health-related quality of life and increase physical activity levels in patients with low exercise capacity Moderate to high-risk elderly patients also benefit from individualized endurance-resistance Background The prevalence and consequences of musculoskeletal pain is considerable among healthcare workers , allegedly due to high physical work dem and s of healthcare work . Previous investigations have shown promising results of physical exercise for relieving pain among different occupational groups , but the question remains whether such physical exercise should be performed at the workplace or conducted as home-based exercise . Performing physical exercise at the workplace together with colleagues may be more motivating for some employees and thus increase adherence . On the other h and , physical exercise performed during working hours at the workplace may be costly for the employers in terms of time spend . Thus , it seems relevant to compare the efficacy of workplace- versus home-based training on musculoskeletal pain . This study is intended to investigate the effect of workplace-based versus home-based physical exercise on musculoskeletal pain among healthcare workers . Methods / Design This study was design ed as a cluster r and omized controlled trial performed at 3 hospitals in Copenhagen , Denmark . Clusters are hospital departments and hospital units . Cluster r and omization was chosen to increase adherence and avoid contamination between interventions . Two hundred healthcare workers from 18 departments located at three different hospitals is allocated to 10 weeks of 1 ) workplace based physical exercise performed during working hours ( using kettlebells , elastic b and s and exercise balls ) for 5 × 10 minutes per week and up to 5 group-based coaching sessions , or 2 ) home based physical exercise performed during leisure time ( using elastic b and s and body weight exercises ) for 5 × 10 minutes per week . Both intervention groups will also receive ergonomic instructions on patient h and ling and use of lifting aides etc . Inclusion criteria are female healthcare workers working at a hospital . Average pain intensity ( VAS scale 0 - 10 ) of the back , neck and shoulder ( primary outcome ) and physical exertion during work , social capital and work ability ( secondary outcomes ) is assessed at baseline and 10-week follow-up . Further , postural balance and mechanical muscle function is assessed during clinical examination at baseline and follow-up . Discussion This cluster r and omized trial will investigate the change in self-rated average pain intensity in the back , neck and shoulder after either 10 weeks of physical exercise at the workplace or at home . Trial registration Clinical Trials.gov ( NCT01921764 ) Background Knee osteoarthritis ( OA ) is a prevalent chronic musculoskeletal condition with no cure . Pain is the primary symptom and results from a complex interaction between structural changes , physical impairments and psychological factors . Much evidence supports the use of strengthening exercises to improve pain and physical function in this patient population . There is also a growing body of research examining the effects of psychologist-delivered pain coping skills training ( PCST ) particularly in other chronic pain conditions . Though typically provided separately , there are symptom , re source and personnel advantages of exercise and PCST being delivered together by a single healthcare professional . Physiotherapists are a logical choice to be trained to deliver a PCST intervention as they already have expertise in administering exercise for knee OA and are cognisant of the need for a biopsychosocial approach to management . No studies to date have examined the effects of an integrated exercise and PCST program delivered solely by physiotherapists in this population . The primary aim of this multisite r and omised controlled trial is to investigate whether an integrated 12-week PCST and exercise treatment program delivered by physiotherapists is more efficacious than either program alone in treating pain and physical function in individuals with knee OA . Methods / design This will be an assessor-blinded , 3-arm r and omised controlled trial of a 12-week intervention involving 10 physiotherapy visits together with home practice . Participants with symptomatic and radiographic knee OA will be recruited from the community in two cities in Australia and r and omized into one of three groups : exercise alone , PCST alone , or integrated PCST and exercise .  R and omisation will be stratified by city ( Melbourne or Brisbane ) and gender . Primary outcomes are overall average pain in the past week measured by a Visual Analogue Scale and physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale . Secondary outcomes include global rating of change , muscle strength , functional performance , physical activity levels , health related quality of life and psychological factors . Measurements will be taken at baseline and immediately following the intervention ( 12 weeks ) as well as at 32 weeks and 52 weeks to examine maintenance of any intervention effects . Specific assessment of adherence to the treatment program will also be made at weeks 22 and 42 . Relative cost-effectiveness will be determined from health service usage and outcome data . Discussion The findings from this r and omised controlled trial will provide evidence for the efficacy of an integrated PCST and exercise program delivered by physiotherapists in the management of painful and functionally limiting knee OA compared to either program alone . Trial registration Australian New Zeal and Clinical Trials Registry reference number : Background It is well recognised that low back pain is a significant public health problem and engagement in moderate levels of physical activity is associated with positive outcomes .Conservative active care , such as exercise , is effective in reducing pain and disability associated with chronic low back pain . However , a rapid decline in clinical outcomes is commonly seen after discharge from treatment . Methods / Design We will conduct a r and omised controlled trial to investigate the effectiveness of a mobile health supported physical activity intervention ( compared to st and ard care ) in care-seeking , pain and disability in people with chronic low back pain after discharge from treatment . We will recruit 68 patients with chronic low back pain following discharge from an outpatient hospital program , who will be r and omly allocated to the physical activity intervention ( n = 34 ) or the st and ard care group ( n = 34 ) and monitored for 6 months . The physical activity intervention will involve a physical activity advice booklet , a face-to-face health coaching session and 12 fortnightly follow-up telephone-based health coaching sessions . This intervention will be supported by provision of a specifically design ed web app and a physical activity monitoring device ( FitBit ) . The st and ard care group will receive the physical activity advice booklet only . Discussion This pilot trial will investigate a new model to prevent clinical decline in people following conservative treatment for chronic low back pain . If proven to be effective , this approach will constitute a major advance in the management of low back pain . Chronic patients who experience recurrent pain and disability after treatment are prone to seek additional care in the form of physiotherapy , medication , emergency department attendance , specialist consultation or spinal surgery . This model aims to maintain functional levels and reduce care-seeking empowering patients to self-manage their low back pain by offering them a contemporary patient-centred physical activity program with the support of mobile health technology . The outcomes of this trial will have immediate implication s for clinical practice .Trial registration ACTRN12615000189527 ( 26 - 02 - 2015 ) BACKGROUND Chronic musculoskeletal pain is prevalent among laboratory technicians and work-related stress may aggravate the problem . OBJECTIVES This study investigated the effect of a multifaceted worksite intervention on pain and stress among laboratory technicians with chronic musculoskeletal pain using individually tailored physical and cognitive elements . STUDY DESIGN This trial uses a single-blind r and omized controlled design with allocation concealment in a 2-armed parallel group format among laboratory technicians . The trial " Implementation of physical exercise at the Workplace (IRMA09)--Laboratory technicians " was registered at Clinical Trials.gov prior to participant enrolment . SETTING The study was conducted at the head division of a large private pharmaceutical company 's research and development department in Denmark . The study duration was March 2014 ( baseline ) to July 2014 ( follow-up ) . METHODS Participants ( n = 112 ) were allocated to receive either physical , cognitive , and mindfulness group-based training ( PCMT group ) or a reference group ( REF ) for 10 weeks at the worksite . PCMT consisted of 4 major elements : 1 ) resistance training individually tailored to the pain affected area , 2 ) motor control training , 3 ) mindfulness , and 4 ) cognitive and behavioral therapy/education . Participants of the REF group were encouraged to follow ongoing company health initiatives . The predefined primary outcome measure was pain intensity ( VAS scale 0 - 10 ) in average of the regions : neck , shoulder , lower and upper back , elbow , and h and at 10 week follow-up . The secondary outcome measure was stress assessed by Cohen´s perceived stress question naire . In addition , an explorative dose-response analysis was performed on the adherence to PCMT with pain and stress , respectively , as outcome measures . RESULTS A significant ( P < 0.0001 ) treatment by time interaction in pain intensity was observed with a between-group difference at follow-up of -1.0 ( 95%CI : -1.4 to -0.6 ) . No significant effect on stress was observed ( treatment by time P = 0.16 ) . Exploratory analyses for each body region separately showed significant pain reductions of the neck , shoulders , upper back and lower back , as well as a tendency for h and pain . Within the PCMT group , general linear models adjusted for age , baseline pain , and stress levels showed significant associations for the change in pain with the number of physical-cognitive training sessions per week ( -0.60 [ 95%CI -0.95 to -0.25 ] ) and the number of mindfulness sessions ( 0.15 [ 95%CI 0.02 to 0.18 ] ) . No such associations were found with the change in stress as outcome . LIMITATIONS Limitations of behavioral interventions include the inability to blind participants to which intervention they receive . Self-reported outcomes are a limitation as they may be influenced by placebo effects and outcome expectations . CONCLUSIONS We observed significant reductions in chronic musculoskeletal pain following a 10-week individually adjusted multifaceted intervention with physical training emphasizing dynamic joint mobility and mindfulness coupled with fear-avoidance and de-catastrophizing behavioral therapy compared to a reference group encouraged to follow on-going company health initiatives . A higher dose of physical-cognitive training appears to facilitate pain reduction , whereas a higher dose of mindfulness appears to increase pain . Hence , combining physical training with mindfulness may not be an optimal strategy for pain reduction . TRIAL REGISTRATION NCT02047669 Abstract Objective To assess the cost effectiveness of adding spinal manipulation , exercise classes , or manipulation followed by exercise ( “ combined treatment ” ) to “ best care ” in general practice for patients consulting with low back pain . Design Stochastic cost utility analysis alongside pragmatic r and omised trial with factorial design . Setting 181 general practice s and 63 community setting s for physical treatments around 14 centres across the United Kingdom . Participants 1287 ( 96 % ) of 1334 trial participants . Main outcome measures Healthcare costs , quality adjusted life years ( QALYs ) , and cost per QALY over 12 months . Results Over one year , mean treatment costs relative to “ best care ” were £ 195 ( $ 360 ; € 279 ; 95 % credibility interval £ 85 to £ 308 ) for manipulation , £ 140 ( £ 3 to £ 278 ) for exercise , and £ 125 ( £ 21 to £ 228 ) for combined treatment . All three active treatments increased participants ' average QALYs compared with best care alone . Each extra QALY that combined treatment yielded relative to best care cost £ 3800 ; in economic terms it had an “ incremental cost effectiveness ratio ” of £ 3800 . Manipulation alone had a ratio of £ 8700 relative to combined treatment . If the NHS was prepared to pay at least £ 10 000 for each extra QALY ( lower than previous recommendations in the United Kingdom ) , manipulation alone would probably be the best strategy . If manipulation was not available , exercise would have an incremental cost effectiveness ratio of £ 8300 relative to best care . Conclusions Spinal manipulation is a cost effective addition to “ best care ” for back pain in general practice . Manipulation alone probably gives better value for money than manipulation followed by exercise Osteoarthritis is the leading cause of persistent knee pain , affecting around one quarter of adults ( 1 , 2 ) , and is a major contributor to global disability ( 3 ) . Knee osteoarthritis causes loss of function , reduced quality of life , and psychological disability ( 4 ) . It has no cure and , given the aging population and increasing obesity rates , disease burden is rapidly increasing ( 5 , 6 ) . The urgent need for effective and accessible models of health service delivery that can be provided on a population level has been recognized as a research priority by key stakeholders ( 7 ) . Such models should take a biopsychosocial approach ; emphasize nondrug , nonsurgical treatment ; and foster self-management , of which appropriate educational information is a core component ( 8) . Exercise has well-established benefits for pain and function in persons with knee osteoarthritis ( 911 ) and is recommended by clinical guidelines as the cornerstone of conservative management ( 12 ) . It is often prescribed by a health professional and can be performed effectively at home ( 9 ) . Evidence also supports  pain-coping skills training ( PCST ) , an approach based on cognitive behavioral principles , to target psychological factors , such as low self-efficacy , poor pain coping , and pain catastrophizing , that are common in persons with chronic pain ( 13 , 14 ) . However , for many , accessing specialist clinicians to prescribe and supervise these treatments may be difficult due to cost , transport issues , or geographic location , particularly in regional and rural areas where services may be limited or nonexistent ( 15 , 16 ) . The Internet is a time-efficient and convenient method to deliver health interventions with broad reach ( 17 , 18 ) . Educational material is often accessed online by persons with chronic pain ( 19 ) . Remotely delivered physiotherapy and exercise can benefit persons with knee pain and osteoarthritis ( 2022 ) and those who have undergone knee joint replacement , albeit often using sophisticated technology ( 23 ) . An Internet-based interactive PCST program ( PainCOACH ) , design ed to translate key therapeutic elements of clinician-delivered face-to-face PCST ( 24 ) , showed improved outcomes in persons with hip or knee osteoarthritis ( 25 ) . An online intervention combining these treatments aligns with a biopsychosocial approach to chronic disease management ( 8) but has not been investigated in this patient population . This study aim ed to evaluate the effectiveness of an innovative Internet-based intervention combining physiotherapist-prescribed home exercise delivered via videoconferencing ( Skype [ Microsoft ] ) and automated PCST in addition to educational material in persons with chronic knee pain . Our primary hypothesis was that the intervention would reduce pain and improve physical function after 3 months compared with educational material only . Supplement . Study Protocol Methods Design Overview We conducted a parallel , 2-group pragmatic r and omized , controlled trial . The protocol has been published ( 26 ) . The trial was prospect ively registered with the Australian New Zeal and Clinical Trials Registry ( ACTRN12614000243617 ) . Initial registration erroneously listed the Depression , Anxiety and Stress Scale ( DASS-21 ) as a secondary outcome rather than an eligibility screening tool . We amended the registry after enrolling 16 participants but before collecting follow-up data . No interim analyses were performed . The Institutional Human Ethics Committee approved the trial , and participants provided informed consent . Recruitment occurred from March 2014 to May 2015 , with follow-up completed in February 2016 . Participants and physiotherapists were unblinded to group allocation and were aware of the alternative treatment components , but study hypotheses were not disclosed to participants . The statistician was blinded . A nested health economic evaluation and a qualitative study exploring patients ' and physiotherapists ' experiences will be published separately . Setting and Participants We recruited community-dwelling participants from Australia via print , radio , and social media advertisements and our data base .  Eligibility was confirmed using an online survey followed by a telephone interview .  Inclusion criteria were age 50 years or older , knee pain for more than 3 months and on most days of the previous month , knee pain during walking ( score of 4 on an 11-point numerical rating scale [ NRS ] , with terminal descriptors of no pain and worst pain possible ) in the previous week , mild to moderate physical dysfunction ( score > 20 out of 68 on the physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index [ WOMAC ] ) , and an active e-mail account and a computer with Internet access . Exclusion criteria were joint replacement in the symptomatic knee , awaiting joint replacement surgery , intra-articular corticosteroid injection or knee surgery in the previous 6 months or planned joint surgery in the subsequent 9 months , treatment for knee pain or participation in a strengthening exercise or PCST program in the previous 6 months , systemic arthritic condition , neurologic condition affecting the lower limb or limiting exercise , pain at another site that was worse than knee pain or limited exercise , and high-level depression ( score > 21 on the depression subscale of the DASS-21 [ 27 ] ) . R and omization and Interventions Computer-generated r and omization was conducted by r and om permuted blocks of size 2 to 8 stratified by sex and residence ( metropolitan or regional/rural ) . The r and omization schedule was prepared by an independent biostatistician and concealed from the research er enrolling participants in sequentially numbered , opaque , sealed envelopes . Intervention Participants received 3 Internet-delivered treatments . The first was educational material about exercise and physical activity , pain management , emotions , healthy eating , complementary therapies , and medications ( www.arthritisaustralia.com.au ) . Participants were encouraged to access the material at their leisure . The second was an interactive automated PCST program ( PainCOACH ) ( 24 , 25 ) . Participants were asked to complete eight 35- to 45-minute modules ( 1 per week commencing in week 1 ) and practice pain-coping skills daily ( Appendix Table 1 ) . These skills included progressive relaxation , activityrest cycling , scheduling pleasant activities , changing negative thoughts , pleasant imagery and distraction techniques , and problem solving . The third was 7 Skype sessions with a physiotherapist over 12 weeks ( in weeks 2 , 3 , 4 , 6 , 8 , 10 , and 12 ) . Sessions lasted 45 minutes in weeks 2 and 12 and 30 minutes in the other weeks . Physiotherapists were allocated to participants on the basis of availability , and the same physiotherapist undertook all consultations with any given participant . The physiotherapist performed a brief assessment and prescribed a lower-limbstrengthening home exercise program to be performed 3 times per week ( 26 , 28 ) ( Appendix Table 2 ) . Exercise progression was provided by varying the exercises , repetitions , load , or difficulty to approximate a 10-repetition maximum level and a self-rated effort level of at least 5 out of 10 ( hard ) on a modified Borg Rating of Perceived Exertion scale ( 29 ) . Participants were provided with instructions , video demonstrations , and equipment ( such as resistance b and s and ankle weights ) . They also were encouraged to increase physical activity levels , received written information about how to do so , and were given the option of using a pedometer for motivation ( provided at no cost ) . Appendix Table 1 . Summary of the Internet-Based PainCOACH Content * Appendix Table 2 . Home Exercise Program Protocol * Generic e-mail reminders to complete PainCOACH modules were sent weekly during the first 8 weeks . At week 11 and at monthly intervals from week 13 , participants received e-mails encouraging them to review the final module , revisit useful or meaningful modules , and continue home exercise and pain-coping skills practice .  Eight physiotherapists ( 4 men ) with an average of 16 years ( range , 3 to 28 years ) of clinical musculoskeletal experience were trained to deliver the exercise component . Physiotherapists attended a 1-day training course conducted by the research ers and were given an exercise manual . They also were provided with an overview of PainCOACH and were asked to encourage participants to complete modules and practice skills . Regular telephone and Skype meetings between the physiotherapists and the research ers were held to discuss implementation of the intervention . A brief video showing a mock physiotherapy session is provided in the Supplement Video . Control The control group received access to the same online educational material as the intervention group . Outcomes and Follow-up Participants completed measurements online at baseline , 3 months ( primary time point ) , and 9 months . They received a $ 50AUD gift voucher for completing all question naires . The primary outcomes were valid and reliable self-reported measures of pain and physical function that are recommended for knee osteoarthritis clinical trials ( 30 ) . Overall average pain during walking over the previous week was measured with an NRS , with terminal descriptors of no pain ( score of 0 ) and worst pain possible ( score of 10 ) and a minimum clinical ly important difference ( MCID ) of 1.8 units ( 31 ) . Difficulty with physical function over the previous 48 hours was measured with the WOMAC ( Likert version 3.1 ) physical function subscale ( 32 ) , with total scores ranging from 0 ( no dysfunction ) to 68 ( maximum dysfunction ) and an MCID of 6 units ( 33 ) . Secondary outcomes included knee pain over the previous 48 hours , measured using the WOMAC pain subscale ( 32 ) ( scores range from 0 [ no pain ] to 20 [ maximum pain ] ) ; global change overall , in pain , and in physical function , measured using 7-point Likert scales with terminal descriptors of much worse to much better ( measured at 3 and 9 months ) ; health-related quality of life , BACKGROUND Although guidelines for the management of low back pain have been published in the past decade , there is potential for further improvement in back pain care . AIM To document the management of non-specific low back pain by general practitioners ( GPs ) in the Netherl and s , to determine how this management of care is related to patient and physician factors , and to explore possible reasons for not adhering to the guidelines . METHOD A prospect i ve study was set up in which 57 GPs in 30 general practice s completed a computerised question naire after each consultation for low back pain during a four-month period . RESULTS Of 1640 back pain contacts , 1180 referred to non-specific low back pain . Diagnostic tests were ordered in 2 % of first consultations and in 7 % of follow-up consultations within one episode . The advice to  stay active  despite  pain  was given in 76 % and 69 % of these cases respectively . Patients were prescribed an  analgesic  in 53 % and 41 % of cases respectively ( mainly NSAIDs [ 80 % ] ) . Patients were referred to a physiotherapist in 22 % of first and in 50 % of follow-up consultations . Older patients were physically examined less often , prescribed analgesics more often , and were told less often that staying active could benefit them . The advice to remain active was omitted more often when symptoms lasted longer . Only a small part of the variance in management was accounted for by patient characteristics or by differences between practice s. CONCLUSION The management of low back pain met the guidelines to a large extent . Management decisions were often related to characteristics in which the guidelines lack differentiation . Important reasons for non-adherence were perceived patients ' preferences . Further implementation of guidelines will be difficult unless doctors ' and patients ' views are more explicitly known Background Evidence suggests that to facilitate physical activity sedentary people may adhere to one component of exercise prescriptions ( intensity , duration or frequency ) without adhering to other components . Some experts have provided evidence for determinants of adherence to different components among healthy people . However , our underst and ing remains scarce in this area for patients with neck or low back pain . The aims of this study are to determine whether patients with neck or low back pain have different rates of adherence to exercise components of frequency per week and duration per session when prescribed with a home exercise program , and to identify if adherence to both exercise components have distinct predictive factors . Methods A cohort of one hundred eighty-four patients with chronic neck or low back pain who attended physiotherapy in eight primary care centers were studied prospect ively one month after intervention . The study had three measurement periods : at baseline ( measuring characteristics of patients and pain ) , at the end of physiotherapy intervention ( measuring characteristics of the home exercise program ) and a month later ( measuring professional behaviors during clinical encounters , environmental factors and self-efficacy , and adherence behavior ) . Results Adherence to duration per session ( 70.9 % ± 7.1 ) was more probable than adherence to frequency per week ( 60.7 % ± 7.0 ) . Self-efficacy was a relevant factor for both exercise components ( p < 0.05 ) . The total number of exercises prescribed was predictive of frequency adherence ( p < 0.05 ) . Professional behaviors have a distinct influence on exercise components . Frequency adherence is more probable if patients received clarification of their doubts ( adjusted OR : 4.1 ; p < 0.05 ) , and duration adherence is more probable if they are supervised during the learning of exercises ( adjusted OR : 3.3 ; p < 0.05 ) . Conclusion We have shown in a clinic-based study that adherence to exercise prescription frequency and duration components have distinct levels and predictive factors . We recommend additional study , and advise that differential attention be given in clinical practice to each exercise component for improving adherence The aim of the present study was to compare the effect of increased aerobic capacity versus muscle strength rehabilitation of female hospital staff with long-lasting musculoskeletal back pain . Seventy-nine women agreed to participate in the intervention study . After a medical examination , 65 individuals were assigned to one of three balanced groups : Endurance training ( aerobic capacity promoting training : ET : n = 22 ) , strength promotion exercise ( SP : n = 24 ) or a control group ( CON : n = 19 ) . The active groups met twice a week for 60 minutes of exercise over 15 weeks . Aerobic capacity ( VO2max ) and musculoskeletal pain were measured immediately before ( T1 ) and after the intervention period ( T2 ) . Aerobic capacity significantly increased in the ET group , whereas no change was observed in the SP group , and a significant reduction was found in the CON group from T1 to T2 . Musculoskeletal pain was significantly reduced in both intervention groups , whereas minor changes were observed in the control group . Results from a 7-month follow-up ( T3 ) survey confirmed the beneficial effects of interventions on musculoskeletal pain . In conclusion , improved aerobic capacity appeared not to be a necessary mechanism in musculoskeletal back pain reduction Context Low back pain causes frequent disability and lost productive time . Contribution This r and omized trial compared a behavioral-oriented grade d activity program with usual care in 134 Dutch airline company workers who had missed work because of persistent low back pain .  Grade d activity consisted of biweekly 1-hour exercise sessions with physiotherapists who emphasized operant-conditioning principles . Over 6 months of follow-up , participants in the grade d activity program missed 58 days of work , while participants receiving usual care missed 87 days . Implication s A behavioral-oriented grade d activity program returned participants with low back pain to work more often than did usual care . The Editors Nonspecific low back pain is an uncomfortable medical condition that causes frequent disability and absence from work . Most episodes of low back pain resolve fairly quickly and cause only short periods of absence from work . However , some workers with low back pain miss work for several days to weeks and are at risk for more permanent disability ( 1 ) . To reduce the individual and socioeconomic burden related to this absenteeism , we need effective intervention strategies in occupational health care setting s that promote safe and rapid return to work . One promising and often-advocated intervention strategy for workers with prolonged nonspecific low back pain is active rehabilitation that is directed toward return to normal activity and work ( 2 ) . Examples are grade d activity interventions that include physical exercise , application of operant-conditioning behavioral principals , and promotion of improved functioning and safe return to work even if pain persists ( 3 - 6 ) . In a r and omized , controlled trial , Lindstrm and colleagues ( 3 , 4 ) found that a grade d activity intervention reduced absence from work more than did traditional care in Swedish workers employed in the automobile industry . We investigate , in a second r and omized , controlled trial , whether absence from work because of low back pain is reduced more with grade d activity intervention than with traditional care in an occupational health care setting in the Netherl and s. Methods Study Design and Sample The study was a single-blind , r and omized , controlled trial in an occupational health services center ( KLM Health , Safety and Environment ) at Schiphol Airport , Amsterdam , the Netherl and s. The center provides occupational health services for all employees of a major Dutch airline ( KLM Royal Dutch Airlines ) . The source sample ( n = 20 000 ) consisted of workers who were employed in the following organizational units of the airline : baggage and aircraft turnaround services , passenger services , engineering and maintenance , cargo , and cabin and cockpit . Workers who were listed as absent from work because of low back pain were invited for a consultation with the occupational physician . Those who were thought to be eligible for inclusion were referred to the research assistant , who judged whether they met the inclusion criteria : full or partial absence from work because of nonspecific low back pain and low back pain symptoms with a minimum duration of 4 weeks in succession . The exclusion criteria were low back pain with radiation below the knee with signs of nerve-root compression ( 7 ) ; cardiovascular contraindications for physical activity , as checked according to the Physical Activities Readiness Question naire ( 8 , 9 ) ; any conflict between worker and employer with legal involvement ; or pregnancy . Workers who met the inclusion criteria were informed of the purpose and procedures of the study and were enrolled after giving informed consent . The Medical Ethical Committee of the VU University Medical Center , Amsterdam , the Netherl and s , approved the study . Treatment Allocation The participants were assigned to grade d activity or usual care on the basis of block r and omization , after prestratification for the organizational unit in the workplace from which they were recruited ( the 5 organizational units listed earlier ) and for the severity of pain symptoms ( scored on a scale of 0 to 10 ; severity scores were < 6 or 6 points ) . This result ed in a total of 10 strata . R and omized , permuted blocks of 4 allocations were generated for each stratum through a computer-generated r and om-sequence table . Opaque , sequentially numbered , sealed envelopes were prepared for each stratum by a research er who was not involved in enrolling the participants or assigning them to their groups . The envelopes contained a sheet of paper that indicated 1 of the 2 interventions . Participants learned their group assignments after a research assistant completed the baseline measurements and delivered the sealed envelopes . Blinding The research assistants who collected the data were blinded to the treatment allocation . All participants were repeatedly asked not to reveal any information about their treatment allocation . The participants and treatment providers were not blinded to treatment allocation . Interventions In the Dutch occupational health care system , occupational physicians guide disabled workers who are absent from work through their disability period . These occupational physicians are employed by occupational health services that are paid for by the companies . The occupational physicians adhere to back pain management strategies that consist of advising workers on ergonomics , prevention , and return-to-work schedules and advising and communicating with other stakeholders ( such as health care providers and representatives of the workplace ) . Disabled workers who participated in the present study were assigned to either grade d activity or usual care within the context of the Dutch occupational health care setting . Grade d Activity The intervention group received the usual guidance from the occupational physician about work-related problems and barriers to return to work as well as the grade d activity intervention supervised by a physiotherapist .  Three physiotherapists who worked in a private practice at Schiphol Airport provided the treatment according to the grade d activity protocol . Two of those physiotherapists were also trained as manual therapists , and 1 was also a human movement scientist . Before the study , the physiotherapists had been specifically trained to treat patients with low back pain according to behavioral principles . A research physiotherapist who was experienced in treating patients with chronic pain in rehabilitation centers instructed the physiotherapists in three 2-hour sessions and practice d patienttherapist interactions with them through role-play . Before the study , the physiotherapists treated several patients according to the grade d activity protocol to gain more experience . The physiotherapists made audiotapes of the intervention sessions before and during the study period . The contents of these audiotapes were assessed and discussed with the research physiotherapist in 3 additional meetings . Furthermore , the physiotherapists summarized the treatment after each session , and research ers used these summaries to review the sessions . The same physiotherapist treated participants each time , except for temporary st and -in sessions that were supervised by colleagues because of holidays or other reasons . Specific therapists were not systematic ally selected to treat specific participants ; selection was based on pragmatic reasons , such as the time available in the work schedules of the physiotherapists or the days of treatment preferred by the participants . Table 1 presents the concept and content of the grade d activity intervention . The intervention consisted of 1-hour exercise sessions that participants attended twice per week until they returned completely to regular work or until the maximum therapy duration of 3 months was reached . At the start of the intervention , the physiotherapist inquired about the participant 's medical history and completed a brief physical examination consisting of flexion , extension , and lateroflexion of the lumbar spine and a brief screening for nerve-root pain ( 10 ) . The purpose of the physical examination was to confirm the diagnosis of benign , nonspecific low back pain and to reduce participants ' fears about any presumed underlying disease . The participants were reassured that despite the annoying pain , nothing was seriously wrong with their backs . Subsequently , the physiotherapist and participant decided on a set of general exercises and individually tailored exercises . Both types of exercises had to be performed during each session . The general exercises were aerobic exercises , such as cycling or rowing , and strengthening exercises for large muscle groups , and most were carried out in a gym while using exercise equipment . The strengthening exercises were a floor abdominal sit-up exercise , a dynamic back extension exercise , a leg-press exercise , a latissimus pull-down exercise , and st and ing up from a low chair .  Participants in the grade d activity group had to perform not only these general exercises but also individually tailored exercises , which imitated physical tasks at work or difficult and painful activities of daily living . For example , a participant who reported back problems while lifting and moving suitcases from a luggage wagon into an airplane might be given an exercise to practice lifting and moving a suitcase with a certain number of repetitions . During the first 3 sessions , the maximal performance ( for example , the maximum number of repetitions ) was assessed for each exercise separately , and the average score for each exercise over the 3 sessions was used as a baseline value for specifying a gradually progressive exercise scheme . Subsequently , the participant was asked to propose a date for full return to regular work , which would consequently be the end point of the physical exercise program . Before returning to full regular work , participants could return to work with modified hours and duties . Advised by the physiotherapist , the participant Purpose To assess effects of 1-year Intelligent Physical Exercise Training ( IPET ) on  musculoskeletal health . Methods Office workers were r and omized 1 : 1 to a training group , TG ( N = 193 ) , or a control group , CG ( N = 194 ) . TG received 1 h supervised high intensity IPET every week within working hours for 1 year and was recommended to perform 30 min of moderate intensity physical activity for 6 days a week during leisure . The IPET program was based on baseline health measures . Results No baseline differences were present . An intention-to-treat analysis showed significant between-group effect for muscle strength but not for musculoskeletal pain . However , a per- protocol analysis of those with an adherence of ≥70 % demonstrated a significant between-group effect for neck pain during the past three months . Several significant within-group changes were present , where TG and TG ≥ 70 % demonstrated clinical ly relevant pain reductions whereas minimal reductions were seen for CG . Conclusion IPET and recommendations of moderate intensity physical activity demonstrated significant between-group effect on muscle strength . Interestingly , significant within-group reductions in musculoskeletal pain were seen not only in TG but also in CG . This may underlie the lack of such between-group effect and shows that a possible positive side effect of merely drawing attention can improve musculoskeletal health OBJECTIVE To determine the point prevalence of chronic musculoskeletal ankle disorders in the community . DESIGN Cross-sectional stratified ( metropolitan vs regional ) r and om sample . SETTING General community . PARTICIPANTS  Population -based computer-aided telephone survey of people ( N=2078 ) aged 18 to 65 years in New South Wales , Australia . Of those contacted , 751 participants provided data . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Point prevalence for no history of ankle injury or chronic ankle problems ( no ankle problems ) , history of ankle injury without residual problems , and chronic ankle disorders . Chronic musculoskeletal ankle disorders due to ankle sprain , fracture , arthritis , or other disorder compared by chi-square test for the presence of pain , weakness , giving way , swelling and instability , activity limitation , and health care use in the past year . RESULTS There were 231 ( 30.8 % ) participants with no ankle problems , 342 ( 45.5 % ) with a history of ankle injury but no chronic problems , and 178 ( 23.7 % ) with chronic ankle disorders . The major component of chronic ankle disorders was musculoskeletal disorders ( n=147 , 19.6 % of the total sample ) , most of which were due to ankle injury ( n=117 , 15.6 % of the total ) . There was no difference among the arthritis , fracture , sprain , and other groups in the prevalence of the specific complaints , or health care use . Significantly more participants with arthritis had to limit activity than in the sprain group ( Chi-square test , P=.035 ) . CONCLUSIONS Chronic musculoskeletal ankle disorders affected almost 20 % of the Australian community . The majority were due to a previous ankle injury , and most people had to limit or change their physical activity because of the ankle disorder Background : Prevalence of musculoskeletal pain is high in jobs with high physical work dem and s. An aerobic exercise intervention targeting cardiovascular health was evaluated for its long term side effects on musculoskeletal pain . Objective : The objective was to investigate if aerobic exercise affects level of musculoskeletal pain from baseline to 4- and 12-months follow-up . Methods : One-hundred- and -sixteen cleaners aged 18–65 years were cluster-r and omized . The aerobic exercise group ( n = 57 ) received worksite aerobic exercise ( 30 min twice a week ) and the reference group ( n = 59 ) lectures in health promotion . Strata were formed according to closest manager ( total 11 strata ) ; clusters were set within strata ( total 40 clusters , 20 in each group ) . Musculoskeletal pain data from eight body regions was collected at baseline and after 4- and 12-months follow-up . The participants stated highest pain in the last month on a scale from 0 , stating no pain , up to 10 , stating worst possible pain . A repeated-measure 2 × 2 multi-adjusted mixed-models design was applied to compare the between-groups differences in an intention to treat analysis . Participants were entered as a r and om effect nested in clusters to account for the cluster-based r and omization . Results : Clinical ly significant reductions ( > 30 % , f 2 > 0.25 ) in the aerobic exercise group , compared to the reference group , in pain intensity in neck , shoulders , arms/wrists were found at 12-months follow-up , and a tendency ( p = 0.07 , f 2 = 0.18 ) to an increase for the knees . At 4-months follow-up the only significant between-group change was an increase in hip pain . Conclusions : This study indicates that aerobic exercise  reduces musculoskeletal pain in the upper extremities , but as an unintended side effect may increase pain in the lower extremities . Aerobic exercise interventions among workers st and ing or walking in the majority of the working hours should tailor exercise to only maintain the positive effect on musculoskeletal pain Background Active approaches including both specific and unspecific exercise are probably the most widely recommended treatment for patients with chronic low back pain but it is not known exactly which types of exercise provide the most benefit . Nordic Walking - power walking using ski poles - is a popular and fast growing type of exercise in Northern Europe that has been shown to improve cardiovascular metabolism . Until now , no studies have been performed to investigate whether Nordic Walking has beneficial effects in relation to back pain . Methods A total of 151 patients with low back and /or leg pain of greater than eight weeks duration were recruited from a hospital based outpatient back pain clinic . Patients continuing to have pain greater than three on the 11-point numeric rating scale after a multidisciplinary intervention were included . Fifteen patients were unable to complete the baseline evaluation and 136 patients were r and omized to receive A ) Nordic walking supervised by a specially trained instructor twice a week for eight weeks B ) One-hour instruction in Nordic walking by a specially trained instructor followed by advice to perform Nordic walking at home as much as they liked for eight weeks or C ) Individual oral information consisting of advice to remain active and about maintaining the daily function level that they had achieved during their stay at the backcenter . Primary outcome measures were pain and disability using the Low Back Pain Rating Scale , and functional limitation further assessed using the Patient Specific Function Scale . Furthermore , information on time off work , use of medication , and concurrent treatment for their low back pain was collected . Objective measurements of physical activity levels for the  supervised and unsupervised Nordic walking groups were performed using accelerometers . Data were analyzed on an intention-to-treat basis . Results No mean differences were found between the three groups in relation to any of the outcomes at baseline . For pain , disability , and patient specific function the supervised Nordic walking group generally faired best however no statistically significant differences were found . Regarding the secondary outcome measures , patients in the supervised group tended to use less pain medication , to seek less concurrent care for their back pain , at the eight-week follow-up . There was no difference between physical activity levels for the supervised and unsupervised Nordic walking groups . No negative side effects were reported . Conclusion We did not find statistically significant differences between eight weeks of supervised or unsupervised Nordic walking and advice to remain active in a group of chronic low back pain patients . Nevertheless , the greatest average improvement tended to favor the supervised Nordic walking group and - taking into account other health related benefits of Nordic walking - this form of exercise may potentially be of benefit to selected groups of chronic back pain patients .Trial registration http://www . Clinical Trials.gov # AIM This paper reports a study of the effects of aquatic exercise on physical fitness ( flexibility , strength and aerobic fitness ) , self-reported physical functioning and pain in adults with osteoarthritis of the hip or knee . BACKGROUND Osteoarthritis is a common cause of disability and a primary reason for hip and knee joint replacement . Exercise is important for preventing and /or managing the functional limitations associated with joint disease . Aquatic exercise is thought to be beneficial and is often recommended for people with osteoarthritis ; however , few studies have examined the effects on people with osteoarthritis , and these have yielded inconsistent results . METHODS A two-group r and omized controlled trial with a convenience sample was used . Participants were recruited from community sources and r and omly assigned to a 12-week aquatic programme or a non-exercise control condition . Data for 38 participants were collected at baseline , week 6 , and week 12 during 2003 and 2004 . Instruments were a st and ard plastic goniometer , a h and held dynamometer , the 6-minute walk test , the multidimensional Health Assessment Question naire , and a visual analogue scale for pain . RESULTS Repeated measures analysis of variance showed that aquatic exercise statistically significantly improved knee and hip flexibility , strength and aerobic fitness , but had no effect on self-reported physical functioning and pain . The exercise adherence rate was 81.7 % , and no exercise-related adverse effect was observed or reported . CONCLUSIONS Beneficial short-term effects of aquatic exercise were found in adults with osteoarthritis of the hip or knee . Although the programme may not offer pain relief or self-reported improvements in physical functioning , results suggest that aquatic exercise does not worsen the joint condition or result in injury . Nurses engaging in disease management and health promotion for these patients should consider recommending or implementing aquatic classes for patients IMPORTANCE Many site-specific , multivariable risk models for predicting the outcome of musculoskeletal pain problems have been published . The overlapping content in these models suggests a common set of generic indicators suitable for use in primary care . OBJECTIVE To investigate whether a brief set of generic prognostic indicators can predict the outcome of musculoskeletal pain in older patients presenting to general practitioners . DESIGN , SETTING , AND PARTICIPANTS A prospect i ve observational cohort study conducted from September 1 , 2006 , through March 31 , 2007 , of consecutive patients 50 years or older presenting with noninflammatory musculoskeletal pain to 1 of the 5 participating general practice s in the United Kingdom . MAIN OUTCOME MEASURES During consultation , the treating physician assessed and recorded 5 brief generic items ( duration of present pain episode , current pain intensity , pain interference with daily activities , presence of multiple-site pain , and ultrashort depression screen ) and recorded their overall prognostic judgment . The primary outcome was patient-rated improvement , which was measured 6 months after consultation and cross-vali date d with repeated measures up to 3 years . RESULTS A total of 194 ( 48.1 % ) of 403 participants were classified as having an unfavorable outcome at 6 months . Inclusion of 3 generic prognostic indicators ( duration of present pain episode , pain interference with daily activities , and presence of multiple-site pain ) in the prognostic model improved on reliance on physicians ' prognostic judgment alone ( C statistic = 0.72 vs 0.62 ; net reclassification index = 0.136 ; proportion correctly classified = 69 % ) . The improvement in prognostic accuracy was attributable to correcting physicians ' tendency toward overoptimistic expectations of outcome . CONCLUSIONS AND RELEVANCE Three easy-to-obtain pieces of information followed by systematic recording of the general practitioners ' prognostic judgment provide a simple generic assessment of prognosis at point of care in older persons presenting with musculoskeletal problems to primary care practice s in the United Kingdom . Such an assessment offers a common foundation for investigating the usefulness of prognostic stratification for guiding management in the consultation across a range of common painful conditions Study Design . Systematic Review . Objectives . To assess the effects of massage therapy for nonspecific low back pain . Summary of Background Data . Low back pain is one of the most common and costly musculoskeletal problems in modern society . Proponents of massage therapy cl aim it can minimize pain and disability , and speed return to normal function . Methods . We search ed MEDLINE , EMBASE , CINAHL from their beginning to May 2008 . We also search ed the Cochrane Central Register of Controlled Trials ( The Cochrane Library 2006 , issue 3 ) , HealthSTAR and Dissertation abstract s up to 2006 . There were no language restrictions . References in the included studies and in review s of the literature were screened . The studies had to be r and omized or quasi-r and omized trials investigating the use of any type of massage ( using the h and s or a mechanical device ) as a treatment for nonspecific low back pain . Two review authors selected the studies , assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group , and extracted the data using st and ardized forms . Both qualitative and meta-analyses were performed . Results . Thirteen r and omized trials were included . Eight had a high risk and 5 had a low risk of bias . One study was published in German and the rest in English . Massage was compared to an inert therapy ( sham treatment ) in 2 studies that showed that massage was superior for pain and function on both short- and long-term follow-ups . In 8 studies , massage was compared to other active treatments . They showed that massage was similar to exercises , and massage was superior to joint mobilization , relaxation therapy , physical therapy , acupuncture , and self-care education . One study showed that reflexology on the feet had no effect on pain and functioning . The beneficial effects of massage in patients with chronic low back pain  lasted at least 1 year after the end of the treatment . Two studies compared 2 different techniques of massage . One concluded that acupuncture massage produces better results than classic ( Swedish ) massage and another concluded that Thai massage produces similar results to classic ( Swedish ) massage . Conclusion . Massage might be beneficial for patients with subacute and chronic nonspecific low back pain , especially when combined with exercises and education . The evidence suggests that acupuncture massage is more effective than classic massage , but this need confirmation . More studies are needed to confirm these conclusions , to assess the impact of massage on return-to-work , and to determine cost-effectiveness of massage  as an intervention for low back pain Low back pain is one of the most common and important musculoskeletal disorders . In addition , chronic low back pain can deteriorate the patient 's physical , psychosocial and socioeconomic status . The objective of this quasi-experimental research was to assess the efficacy of an aerobic exercise and health education program in the treatment of chronic low back pain .  Seventy-two patients whose ages ranged from 30 to 50 years who had chronic low back pain were enrolled and r and omly assigned into two groups . Eight men and 28 women in the experimental group participated in a series of 3 health education sessions and an aerobic exercise training program . Nine men and 27 women in the control group received regular health education and a lumbar flexion exercise program . After a 3-month period of treatment , the results revealed the experimental group had statistically significant improvement of pain score and resting pulse rates when compared to the values of the control group ( p-value < 0.001 and < 0.01 , respectively ) . The average serum High Density Lipoprotein-Cholesterol ( HDL-C ) in the experimental group was also significantly higher ( p-value < 0.05 ) than that of the control group . This health education program is useful and may be applicable to patients with chronic low back pain  as an alternative treatment Abstract Objective To estimate the effect of adding exercise classes , spinal manipulation delivered in NHS or private premises , or manipulation followed by exercise to “ best care ” in general practice for patients consulting with back pain . Fig 1 Progress of the UK BEAM trial Design Pragmatic r and omised trial with factorial design . Setting 181 general practice s in Medical Research Council General Practice Research Framework ; 63 community setting s around 14 centres across the United Kingdom . Participants 1334 patients consulting their general practice s about low back pain . Main outcome measures Scores on the Rol and Morris disability question naire at three and 12 months , adjusted for centre and baseline scores . Results All groups improved over time . Exercise  improved mean disability question naire scores at three months by 1.4 ( 95 % confidence interval 0.6 to 2.1 ) more than “ best care . ” For manipulation the additional improvement was 1.6 ( 0.8 to 2.3 ) at three months and 1.0 ( 0.2 to 1.8 ) at 12 months . For manipulation followed by exercise the additional improvement was 1.9 ( 1.2 to 2.6 ) at three months and 1.3 ( 0.5 to 2.1 ) at 12 months . No significant differences in outcome occurred between manipulation in NHS premises and in private premises . No serious adverse events occurred . Conclusions Relative to “ best care ” in general practice , manipulation followed by exercise achieved a moderate benefit at three months and a small benefit at 12 months ; spinal manipulation achieved a small to moderate benefit at three months and a small benefit at 12 months ; and exercise achieved a small benefit at three months but not 12 months In this study , three types of treatments for chronic musculoskeletal pain were compared . Fifty-seven patients who suffered from chronic back pain and 21 patients who suffered from temporom and ibular pain and dysfunction were r and omly assigned to either electromyographic ( EMG ) biofeedback , cognitive-behavioral therapy , or conservative medical treatment . At posttreatment , improvements were noted in all three treatment groups , with the biofeedback group displaying the most substantial change . At the 6- and 24-month follow-up , only the biofeedback group maintained significant reductions in pain severity , interference , affective distress , pain-related use of the health care system , stress-related reactivity of the affected muscles , and an increase in active coping self-statements . Treatment outcome was predicted by chronicity and treatment-specific variables . Analysis of attrition showed a significant effect for therapist and extent of somatic pathology . Results suggest that pain patients who suffer from musculoskeletal pain problems and display few physical disabilities may profit the most from short-term EMG biofeedback treatment Study Design . This study was a prospect i ve , r and omized , controlled study . Objective . To compare the effectiveness of aquatic exercise interventions with l and -based exercises in the treatment of chronic low back pain ( CLBP ) . Summary of Background Data . L and -based exercise and physiotherapy are the main treatment tools used for CLBP . Clinical experience indicates that aquatic exercise may have advantages for patients with musculoskeletal disorders . Methods . A total of 65 patients with CLBP were included in this study . Patients were r and omly assigned to receive aquatic exercise or l and -based exercise treatment protocol . Aquatic exercise program consisted of 20 sessions , 5 × per week for 4 weeks in a swimming pool at 33 ° C . L and -based exercise ( home-based exercise ) program were demonstrated by a physiotherapist on one occasion and then they were given written advice The patients were assessed for spinal mobility , pain , disability , and quality of life . Evaluations were performed before treatment ( week 0 ) and after treatment ( week 4 and week 12 ) . Results . In both groups , statistically significant improvements were detected in all outcome measures ( except modified Schober test ) compared with baseline . However , improvement in modified Oswestry Low Back Pain Disability question naire and physical function and role limitations due to physical functioning subpart of Short-Form 36 Health Survey were better in aquatic exercise group ( P < 0.05 ) . Conclusion . It is concluded that a water-based exercises produced better improvement in disability and quality of life of the patients with CLBP than l and -based exercise OBJECTIVE Numerous studies has shown that regular physical exercise can reduce musculoskeletal pain , but the optimal setting to achieve high adherence and effectiveness remains unknown . This study investigated the effect of workplace versus home-based physical exercise on musculoskeletal pain among healthcare workers . METHODS The r and omized controlled trial ( RCT ) comprised 200 female healthcare workers from 18 departments at 3 hospitals . Participants were r and omly allocated at the cluster level to ten weeks of : ( i ) workplace physical exercise ( WORK ) performed during working hours for 5 × 10 minutes per week and up to 5 group-based coaching sessions on motivation for regular physical exercise , or ( ii ) home-based physical exercise ( HOME ) performed during leisure time for 5 × 10 minutes per week . Both groups received ergonomic counseling on patient h and ling and use of lifting aides . Average pain intensity ( 0 - 10 scale ) in the low back and neck/shoulder was the primary outcome . RESULTS Per week , 2.2 ( SD 1.1 ) and 1.0 ( SD 1.2 ) training sessions were performed in WORK and HOME groups , respectively . Pain intensity , back muscle strength and use of analgesics improved more following WORK than HOME ( P<0.05 ) . Between-group differences at follow-up ( WORK versus HOME ) was -0.7 points for pain intensity [ 95 % confidence interval ( 95 % CI ) -1.0- -0.3 ] , 5.5 Nm for back muscle strength ( 95 % CI 2.0 - 9.0 ) , and -0.4 days per week for use of analgesics ( 95 % CI -0.7- -0.2 ) . The effect size for between-group differences in pain intensity was small ( Cohen 's d=0.31 ) . CONCLUSIONS Workplace physical exercise is more effective than home-based exercise in reducing musculoskeletal pain , increasing muscle strength and reducing the use of analgesics among healthcare workers Context Yoga combines exercise with achieving a state of mental focus through breathing . In the United States , 1 million people practice yoga for low back pain . Contribution The authors recruited patients who had a recent primary care visit for low back pain and r and omly assigned 101 to yoga or conventional exercise or a self-care book . Patients in the yoga and exercise groups reported good adherence at 26 weeks . Compared with self-care , symptoms were milder and function was better with yoga . The exercise group had intermediate outcomes . Symptoms improved between 12 and 26 weeks only with yoga . Implication s Yoga was a more effective treatment for low back pain than a self-care book . The Editors Most treatments for chronic low back pain have modest efficacy at best ( 1 ) . Exercise is one of the few proven treatments for chronic low back pain ; however , its effects are often small , and no form has been shown to be clearly better than another ( 2 - 5 ) . Yoga , which often couples physical exercise with breathing , is a popular alternative form of mindbody therapy . An estimated 14 million Americans practice d yoga in 2002 ( 6 ) , including more than 1 million who used it as a treatment for back pain ( 7 , 8) . Yoga may benefit patients with back pain simply because it involves exercise or because of its effects on mental focus . We found no published studies in western biomedical literature that evaluated yoga for chronic low back pain ; therefore , we design ed a clinical trial to evaluate its effectiveness and safety for this condition . Methods Study Design and Setting This r and omized , controlled trial compared the effects of yoga classes with conventional exercise classes and with a self-care book in patients with low back pain  that persisted for at least 12 weeks . The study was conducted at Group Health Cooperative , a nonprofit , integrated health care system with approximately 500000 enrollees in Washington State and Idaho . The Group Health Cooperative institutional review board approved the study protocol , and all study participants gave oral informed consent before the eligibility screening and written consent before the baseline interview and r and omization . Patients Patients from Group Health Cooperative were recruited for 12-week sessions of classes that were conducted between June and December 2003 . We mailed letters describing the study to 6913 patients between 20 and 64 years of age who had visited a primary care provider for treatment of back pain 3 to 15 months before the study ( according to electronic visit records ) . We also advertised the study in the health plan 's consumer magazine . Patients were informed that we were comparing 3 approaches for the relief of back pain and that each was design ed to help reduce the negative effects of low back pain on people 's lives . A research assistant telephoned patients who returned statements of interest to assess their eligibility . After we received their signed informed consent forms , eligible patients were telephoned again for collection of baseline data and r and omization to treatment . We excluded individuals whose back pain was complicated ( for example , sciatica , previous back surgery , or diagnosed spinal stenosis ) , potentially attributable to specific underlying diseases or conditions ( for example , pregnancy , metastatic cancer , spondylolisthesis , fractured bones , or dislocated joints ) , or minimal ( rating of less than 3 on a bothersomeness scale of 0 to 10 ) . We also excluded individuals who were currently receiving other back pain treatments or had participated in yoga or exercise training for back pain in the past year , those with a possible disincentive to improve ( such as patients receiving workers ' compensation or those involved in litigation ) , and those with unstable medical or severe psychiatric conditions or dementia . Patients who had contraindications ( for example , symptoms consistent with severe disk disease ) or schedules that precluded class participation , those who were unwilling to practice at home , or those who could not speak or underst and English were also excluded . R and omization Protocol Participants were r and omly assigned to participate in yoga or exercise classes or to receive the self-care book . We r and omly generated treatment assignments for each class series by using a computer program with block sizes of 6 or 9 . A research er who was not involved in patient recruitment or r and omization placed the assignments in opaque , sequentially numbered envelopes , which were stored in a locked filing cabinet until needed for r and omization . Interventions The yoga and exercise classes developed specifically for this study consisted of 12 weekly 75-minute classes design ed to benefit people with chronic low back pain . In addition to attending classes held at Group Health facilities , participants were asked to practice daily at home . Participants received h and outs that described home practice s , and yoga participants received auditory compact discs to guide them through the sequence of postures with the appropriate mental focus ( examples of postures are shown in the Appendix Figure ) . Study participants retained access to all medical care provided by their insurance plan . Appendix Figure . Yoga postures Yoga We chose to use viniyoga , a therapeutically oriented style of yoga that emphasizes safety and is relatively easy to learn . Our class instructor and a senior teacher of viniyoga , who has + written a book about its therapeutic uses ( 9 ) , design ed the yoga intervention for patients with back pain who did not have previous yoga experience . Although all the sessions emphasized use of postures and breathing for managing low back symptoms , each had a specific focus : relaxation ; strength-building , flexibility , and large-muscle movement ; asymmetric poses ; strengthening the hip muscles ; lateral bending ; integration ; and customizing a personal practice . The postures were selected from a core of 17 relatively simple postures , some with adaptations ( Appendix Table ) , and the sequence of the postures in each class was performed according to the rudiments of viniyoga ( 9 ) . Each class included a question - and -answer period , an initial and final breathing exercise , 5 to 12 postures , and a guided deep relaxation . Most postures were not held but were repeated 3 or 6 times . Exercise Because we could not identify a clearly superior form of therapeutic exercise for low back pain from the literature , a physical therapist design ed a 12-session class series that was 1 ) different from what most participants would have probably experienced in previous physical therapy sessions ( to maximize adherence ) and 2 ) similar to the yoga classes in number and length . We included a short educational talk that provided information on proper body mechanics , the benefits of exercise and realistic goal setting , and overcoming common barriers to developing an exercise routine ( for example , fear ) . Each session began with the educational talk ; feedback from the previous week ; simple warm-ups to increase heart rate ; and repetitions of a series of 7 aerobic exercises and 10 strengthening exercises that emphasized leg , hip , abdominal , and back muscles . Over the course of the 12-week series , the number of repetitions of each aerobic and strength exercise increased from 8 to 30 in increments of 2 . The strengthening exercises were followed by 12 stretches for the same muscle groups ; each stretch was held for 30 seconds . Classes ended with a short , unguided period of deep , slow breathing . Self-Care Book Participants were mailed a copy of The Back Pain Helpbook ( 10 ) , an evidence -based book that emphasized such self-care strategies as adoption of a comprehensive fitness and strength program , appropriate lifestyle modification , and guidelines for managing flare-ups . Although we did not provide any instructions for using the book , many of the chapters concluded with specific action items . Outcome Measures Interviewers who were masked to the treatment assignments conducted telephone interviews at baseline and at 6 , 12 , and 26 weeks after r and omization . The baseline interview collected information regarding sociodemographic characteristics , back pain history , and the participant 's level of knowledge about yoga and exercise . Participants were asked to describe their current pain and to rate their expectations for each intervention . The primary outcomes were back-related dysfunction and symptoms , and the primary time point of interest was 12 weeks . We used the modified Rol and Disability Scale ( 11 ) to measure patient dysfunction by totaling the number of positive responses to 23 questions about limitations of daily activities that might arise from back pain . This scale has been found to be valid , reliable , and sensitive to change ( 12 - 14 ) ; research ers estimate that the minimum clinical ly significant difference on the Rol and scale ranges from 2 to 3 points ( 13 , 15 ) . Participants rated how bothersome their back pain had been during the previous week on an 11-point scale , in which 0 represented not at all bothersome and 10 represented extremely bothersome ; a similar measure demonstrated substantial construct validity in earlier research ( 13 ) . Estimates of the minimum clinical ly significant difference on the bothersomeness scale were approximately 1.5 points ( 16 , 17 ) . Secondary outcome measures were general health status , which we assessed by conducting the Short Form-36 Health Survey ( 18 ) ; degree of restricted activity as determined by patient responses to 3 questions ( 19 ) ; and medication use . After all outcomes data were collected , we asked questions related to specific interventions ( for example , Did you practice at home ? ) . At the 12-week interview , we asked class participants about any pain or substantial discomfort they experienced as a result of the classes . We assessed adherence to the home practice recommendations by asking class participants to complete weekly home practice logs and by asking about home practice during the follow-up Background The effect of exercise on specific impairments and activity limitations in people with hip osteoarthritis ( OA ) is limited . Objective The study objective was to evaluate the long-term effect of exercise therapy and patient education on range of motion ( ROM ) , muscle strength , physical fitness , walking capacity , and pain during walking in people with hip OA . Design This was a secondary outcome analysis of a r and omized clinical trial . Setting The setting was a university hospital . Participants One hundred nine people with clinical ly and radiographically evident hip OA were r and omly allocated to receive both exercise therapy and patient education ( exercise group ) or patient education only ( control group ) . Intervention All participants attended a patient education program consisting of 3 group meetings led by 2 physical therapists . Two other physical therapists were responsible for providing the exercise therapy program , consisting of 2 or 3 weekly sessions of strengthening , functional , and stretching exercises over 12 weeks . Both interventions were conducted at a sports medicine clinic . Measurements Outcome measures included ROM , isokinetic muscle strength , predicted maximal oxygen consumption determined with the Astr and bicycle ergometer test , and distance and pain during the Six-Minute Walk Test ( 6MWT ) . Follow-up assessment s were conducted 4 , 10 , and 29 months after enrollment by 5 physical therapists who were unaware of group allocations . Results No significant group differences were found for ROM , muscle strength , predicted maximal oxygen consumption , or distance during the 6MWT over the follow-up period , but the exercise group had less pain during the 6MWT than the control group at 10 months ( mean difference=−8.5 mm ; 95 % confidence interval=−16.1 , −0.9 ) and 29 months ( mean difference=−9.3 mm ; 95 % confidence interval=−18.1 , −0.6 ) . Limitations Limitations of the study were reduced statistical power and 53 % rate of adherence to the exercise therapy program . Conclusions The previously described effect of exercise on self-reported function was not reflected by beneficial results for ROM , muscle strength , physical fitness , and walking capacity , but exercise in addition to patient education result ed in less pain during walking in the long term OBJECTIVES Joint hypermobility ( JH ) or " ligamentous laxity " is felt to be an underlying risk factor for many types of musculoskeletal presentation in paediatrics , and joint hypermobility syndrome ( JHS ) describes such disorders where symptoms become chronic , often more generalized and associated with functional impairment . Clinical features are felt to have much in common with more severe disorders , including Ehlers-Danlos syndrome ( EDS ) , osteogenesis imperfecta and Marfan syndrome , although this has not been formally studied in children . We defined the clinical characteristics of all patients with joint hypermobility-related presentations seen from 1999 to 2002 in a tertiary referral paediatric rheumatology unit . METHODS Patients were identified and recruited from paediatric rheumatology clinic and ward , and a dedicated paediatric rheumatology hypermobility clinic at Great Ormond Street Hospital . Data were collected retrospectively on the patients from the paediatric rheumatology clinics ( 1999 - 2002 ) and prospect ively on patients seen in the hypermobility clinic ( 2000 - 2002 ) . Specifically , historical details of developmental milestones , musculoskeletal or soft tissue diagnoses and symptoms , and significant past medical history were recorded . Examination features sought included measurements of joint and soft tissue laxity , and associated conditions such as scoliosis , dysmorphic features , cardiac murmurs and eye problems . RESULTS One hundred and twenty-five children ( 64 females ) were included on whom sufficient clinical data could be identified and who had clinical problems ascribed to JH present for longer than 3 months . Sixty-four were from the paediatric rheumatology clinic and 61 from the hypermobility clinic . No differences were found in any of the measures between the two population s and results are presented in a combined fashion . Three-quarters of referrals came from paediatricians and general practitioners but in only 10 % was hypermobility recognized as a possible cause of joint complaint . The average age at onset of symptoms was 6.2 yr and age at diagnosis 9.0 yr , indicating a 2- to 3-yr delay in diagnosis . The major presenting complaint was arthralgia in 74 % , abnormal gait in 10 % , apparent joint deformity in 10 % and back pain in 6 % . Mean age at first walking was 15.0 months ; 48 % were considered " clumsy " and 36 % as having poor coordination in early childhood . Twelve per cent had " clicky " hips at birth and 4 % actual congenital dislocatable hip . Urinary tract infections were present in 13 and 6 % of the female and male cases , respectively . Thirteen and 14 % , respectively , had speech and learning difficulties diagnosed . A history of recurrent joint sprains was seen in 20 % and actual subluxation/dislocation of joints in 10 % . Forty per cent had experienced problems with  h and writing tasks  , 48 % had major limitations of school-based physical education activities , 67 % other physical activities and 41 % had missed significant periods of schooling because of symptoms . Forty-three per cent described a history of easy bruising . Examination revealed that 94 % scored > or = 4/9 on the Beighton scale for generalized hypermobility , with knees ( 92 % ) , elbows ( 87 % ) , wrists ( 82 % ) , h and metacarpophalangeal joints ( 79 % ) , and ankles ( 75 % ) being most frequently involved . CONCLUSIONS JHS is poorly recognized in children with a long delay in the time to diagnosis . Although there is a referral bias towards joint symptoms , a surprisingly large proportion is associated with significant neuromuscular and motor development problems . Our patients with JHS also show many overlap features with genetic disorders such as EDS and Marfan syndrome . The delay in diagnosis results in poor control of pain and disruption of normal home life , schooling and physical activities . Knowledge of the diagnosis and simple interventions are likely to be highly effective in reducing the morbidity and cost to the health and social services BACKGROUND Chronic knee pain is a major cause of disability in the elderly . Management guidelines recommend exercise and self-management interventions as effective treatments . The authors previously described a rehabilitation programme integrating exercise and self-management [ Enabling Self-management and Coping with Arthritic knee Pain through Exercise ( ESCAPE-knee pain ) ] that produced short-term improvements in pain and physical function , but sustaining these improvements is difficult . Moreover , the programme is untried in clinical environments , where it would ultimately be delivered . OBJECTIVES To establish the feasibility of ESCAPE-knee pain and compare its clinical effectiveness and costs with outpatient physiotherapy . DESIGN Pragmatic , r and omised controlled trial . SETTING Outpatient physiotherapy department and community centre . PARTICIPANTS Sixty-four people with chronic knee pain . INTERVENTIONS Outpatient physiotherapy compared with ESCAPE-knee pain . OUTCOMES The primary outcome was physical function assessed using the Western Ontario and McMaster Universities Osteoarthritis Index . Secondary outcomes included pain , objective functional performance , anxiety , depression , exercise-related health beliefs and healthcare utilisation . All outcomes were assessed at baseline and 12 months after completing the interventions ( primary endpoint ) . ANCOVA investigated between-group differences . RESULTS Both groups demonstrated similar improvements in clinical outcomes . Outpatient physiotherapy cost pound 130 per person and the healthcare utilisation costs of participants over 1 year were pound 583 . The ESCAPE-knee pain  programme cost pound 64 per person and the healthcare utilisation costs of participants over 1 year were pound 320 . CONCLUSIONS ESCAPE-knee pain can be delivered as a community-based integrated rehabilitation programme for people with chronic knee pain . Both ESCAPE-knee pain and outpatient physiotherapy produced sustained physical and psychosocial benefits , but ESCAPE-knee pain cost less and was more cost-effective Background Low back pain is a relevant public health problem , being an important cause of work absenteeism worldwide , as well as affecting the quality of life of sufferers and their individual functional performances . Supervised active physical routines and of cognitive-behavioral therapies are recommended for the treatment of chronic Low back pain , although evidence to support the effectiveness of different techniques is missing . Accordingly , the aim of this study is to contrast the effectiveness of two types of exercises , grade d activity or supervised , in decreasing symptoms of chronic low back pain . Methods / design Sample will consist of 66 patients , blindly allocated into one of two groups : 1 ) Grade d activity which , based on an operant approach , will use time-contingent methods aim ing to increase participants ’ activity levels ; 2 ) Supervised exercise , where participants will be trained for strengthening , stretching , and motor control targeting different muscle groups . Interventions will last one hour , and will happen twice a week for 6 weeks . Outcomes ( pain , disability , quality of life , global perceived effect , return to work , physical activity , physical capacity , and kinesiophobia ) will be assessed at baseline , at treatment end , and three and six months after treatment end . Data collection will be conducted by an investigator blinded to treatment allocation . Discussion This project describes the r and omisation method that will be used to compare the effectiveness of two different treatments for chronic low back pain : grade d activity and supervised exercises . Since optimal approach for patients with chronic back pain have yet not been defined based on evidence , good quality studies on the subject are necessary . Trial registration Background The evidence that exercise intervention is effective for treatment of chronic low back pain comes from trials that are not placebo-controlled . Objective The purpose of this study was to investigate the efficacy of motor control exercise for people with chronic low back pain . Design This was a r and omized , placebo-controlled trial . Setting The study was conducted in an outpatient physical therapy department in Australia . Patients The participants were 154 patients with chronic low back pain of more than 12 weeks ’ duration . Intervention Twelve sessions of motor control exercise ( ie , exercises design ed to improve function of specific muscles of the low back region and the control of posture and movement ) or placebo ( ie , detuned ultrasound therapy and detuned short-wave therapy ) were conducted over 8 weeks . Measurements Primary outcomes were pain intensity , activity ( measured by the Patient-Specific Functional Scale ) , and patient 's global impression of recovery measured at 2 months . Secondary outcomes were pain ; activity ( measured by the Patient-Specific Functional Scale ) ; patient 's global impression of recovery measured at 6 and 12 months ; activity limitation ( measured by the Rol and -Morris Disability Question naire ) at 2 , 6 , and 12 months ; and risk of persistent or recurrent pain at 12 months . Results The exercise intervention  improved activity and patient 's global impression of recovery but did not clearly reduce pain at 2 months . The mean effect of exercise on activity ( measured by the Patient-Specific Functional Scale ) was 1.1 points ( 95 % confidence interval [CI]=0.3 to 1.8 ) , the mean effect on global impression of recovery was 1.5 points ( 95 % CI=0.4 to 2.5 ) , and the mean effect on pain was 0.9 points ( 95 % CI=−0.01 to 1.8 ) , all measured on 11-point scales . Secondary outcomes also favored motor control exercise . Limitation Clinicians could not be blinded to the intervention they provided . Conclusions Motor control exercise produced short-term improvements in global impression of recovery and activity , but not pain , for people with chronic low back pain . Most of the effects observed in the short term were maintained at the 6- and 12-month follow-ups Background Hip and knee osteoarthritis is a common cause of pain and disability , which can be improved by exercise interventions . However , regular exercise is uncommon in this group because the low physical activity level in the general population is probably reduced even further by pain related fear of movement . The best method of encouraging increased activity in this patient group is not known . A booklet has been developed for patients with hip or knee osteoarthritis . It focuses on changing disadvantageous beliefs and encouraging increased physical activity . Methods / Design This paper describes the design of a Phase II r and omised controlled trial ( RCT ) to test the effectiveness of this new booklet for patients with hip and knee osteoarthritis in influencing illness and treatment beliefs , and to assess the feasibility of conducting a larger definitive RCT in terms of health status and exercise behaviour . A computerised search of four general medical practice patients ' record data bases will identify patients older than 50 years of age who have consulted with hip or knee pain in the previous twelve months . A r and om sample of 120 will be invited to participate in the RCT comparing the new booklet  with a control booklet , and we expect 100 to return final question naires . This trial will assess the feasibility of recruitment and r and omisation , the suitability of the control intervention and outcome measurement tools , and will provide an estimate of effect size . Outcomes will include beliefs about hip and knee pain , beliefs about exercise , fear avoidance , level of physical activity , health status and health service costs . They will be measured at baseline , one month and three months . Discussion We discuss the merits of testing effectiveness in a phase II trial , in terms of intermediate outcome measures , whilst testing the processes for a larger definitive trial . We also discuss the advantages and disadvantages of testing the psychometric properties of the primary outcome measures concurrently with the trial . Trial registration Current Controlled Trials IS RCT Background Chronic low back pain ( CLBP ) is a persistent disabling condition with rising significant healthcare , social and economic costs . Current research supports the use of exercise-based treatment approaches that encourage people with CLBP to assume a physically active role in their recovery . While international clinical guidelines and systematic review s for CLBP support supervised group exercise as an attractive first-line option for treating large numbers of CLBP patients at low cost , barriers to their delivery include space and time restrictions in healthcare setting s and poor patient attendance . The European Clinical Guidelines have identified the need for research in the use of brief/minimal contact self-activation interventions that encourage participation in physical activity for CLBP . Walking may be an ideally suited form of individualized exercise prescription as it is easy to do , requires no special skills or facilities , and is achievable by virtually all ages with little risk of injury , but its effectiveness for LBP is unproven . Methods and design This study will be an assessor-blinded r and omized controlled trial that will investigate the difference in clinical effectiveness and costs of an individualized walking programme and a supervised general exercise programme compared to usual physiotherapy , which will act as the control group , in people with chronic low back pain . A sample of 246 patients will be recruited in Dublin , Irel and through acute general hospital outpatient physiotherapy departments that provide treatment for people with CLBP . Patients will be r and omly allocated to one of the three groups in a concealed manner . The main outcomes will be functional disability , pain , quality of life , fear avoidance , back beliefs , physical activity , satisfaction and costs , which will be evaluated at baseline , and 3 , 6 and 12 months [ follow-up by pre-paid postage ] . Qualitative telephone interviews and focus groups will be embedded in the research design to obtain feedback about participants ' experiences of the interventions and trial participation , and to inform interpretation of the quantitative data . Planned analysis will be by intention to treat ( quantitative data ) and thematic analysis ( qualitative data ) Discussion The trial will evaluate the effectiveness of a walking programme and a supervised general exercise programme compared to usual physiotherapy in people with CLBP.Trial registration Current controlled trial IS RCT BACKGROUND AND PURPOSE Therapeutic exercise has been shown to be beneficial in decreasing pain and in increasing functioning in patients with chronic low back pain . However , longitudinal follow-up studies are small in number , and often limited in the numbers of subjects due to drop-outs . In addition there is a shortage of real control groups in most cases . The purpose of the present study was to describe long-term changes in intensity of low back pain and in functioning for two study groups five years after undertaking a home exercise programme . METHOD This was a r and omized follow-up study over five years . Fifty-seven subjects were reassessed with question naires five years after their initial recruitment for an intervention study . A home exercise group ( n = 29 ) , with training once a day , and a control group ( n = 28 ) , without exercise , were included in the present study protocol . The primary outcome measurements included a question naire on the intensity of low back pain ( Borg CR-10 scale ) and on functioning ( Oswestry Disability Index ; ODI ) . The confounding physical activity was controlled with metabolic unit ( MET ) values . RESULTS The CR-10 and ODI scores decreased during the first three months in both study groups . During the follow-ups , the corresponding indicators of the home exercise group remained below baseline values . The CR-10 score was significantly lower in the home exercise group ( p = 0.01 ) during the last five-year follow-up session compared with the control group . Overall physical activity decreased slightly during the five-year follow-up , but there were no differences between the two study groups . CONCLUSIONS The present r and omized study indicates that supervised , controlled home exercises lead to reduced low back pain , and that positive effects were preserved over five years Study Design . A 5-year prospect i ve cohort study was conducted of men and women seeking care for a new period of low back pain ( LBP ) . Objectives . To study the natural course of pain and disability due to LBP during a 5-year follow-up period , and to investigate the possible influence of regular physical exercise on recovery . Summary of Background Data . LBP is major health problem , but its natural course is not very well studied . Several studies have investigated the role of physical exercise on LBP disorders , with inconsistent results . Methods . At baseline , a total of 790 subjects seeking care for LBP were interviewed about physical exercise during leisure time . Over 5 years , 3 follow-up assessment s were made by postal question naire . At all measuring points , pain intensity ratings and disability scores were compared between men and women , and among 3 exercise categories . Results . The pain intensity and disability scores were improved after 5 years for both men and women . The most prominent improvements occurred after 6 months , but less so thereafter . There were no significant differences between men and women with regard to individual changes at the 5-year follow-up concerning the pain intensity or disability scores . There were no significant differences , either for women or men , between low , median , or high intensity exercise groups regarding pain intensity or disability values for the individual change at the 5-year follow-up . Conclusions . Over a 5-year period , both men and women who had sought care for LBP reported a decrease in pain and disability ; however , only a few were fully restored . In this study , we found no effect of nonspecific physical exercise on recovery from LBP in men and women This prospect i ve controlled study examined changes in fitness , health , and work ability after a work-oriented physical fitness course arranged for lumberjacks experiencing low back pain but being still at work . The 1-week courses were design ed to activate exercising during leisure time and consisted of fitness tests , various types of exercise , and lectures .  Eighty-seven lumberjacks participated in the courses and 61 subjects served as controls .  Question naire data obtained before and 1 year after the course were available for 78 ( 90 % ) of the course participants and 41 ( 67 % ) of the controls . In the intervention group , perceived fitness , health , and work ability improved and ergonomic strain at work decreased . Both groups reported an increased frequency of leisure-time physical activity . There were between- group differences in the development of fitness , health , distress symptoms , and subjective work ability , whereas the changes in physical activity , back and musculoskeletal symptoms , or ergonomic strain did not differ between the groups . In a 6-month follow up , muscle function improved in the intervention group , but no change was observed in aerobic capacity . There was a tendency of the number of back pain-related sickness leaves , but not of their duration , to develop more favorably in the intervention group , when data from the year before and the year after the course were compared Study Design . A population cohort study to determine the 1-year persistence of neck pain . Objectives . The aim of this study was to determine the persistence of  neck pain  over a 12-month period among the general adult population and to explore socio-demographic , health-related , occupational , physical , and lifestyle factors that might be linked to such persistence . Summary of Background Data . Musculoskeletal clinicians report that neck patients frequently return to consult for recurring episodes of pain . However , the persistent nature of neck pain has been less research ed than other common chronic pain syndromes . Methods . First , to identify a cohort of current neck pain sufferers , a baseline cross-sectional survey was conducted in a general population of 7,669 adults , 18 to 75 years of age , registered with two primary care practice s in South Manchester , UK . The second phase was a follow-up survey , 12 months later , to determine the 1-year persistence of neck pain among those who had reported neck pain at baseline . Persistence of neck pain was compared across groups of responders stratified by potential prognostic factors measured at baseline . “ Persistent ” neck pain was defined according to shading within the region of the neck on a blank body mannequin . The term “ persistent ” neck pain could therefore reflect chronic , recurrent , or continuous pain . Results . There were 1,359 neck pain responders in the baseline survey , and these subjects formed the study population for the prospect i ve study . At follow-up , 786 ( 58 % ) subjects responded , of whom 48 % reported having neck pain lasting for more than 1 day , during the previous month . Significant baseline characteristics , which independently predicted persistent neck pain , were age ( odds ratio [ OR ] = 3.4 ) , being off work at the time of the baseline survey ( OR = 1.6 ) , comorbid low back pain ( OR = 1.6 ) , and cycling as a regular activity ( OR = 2.4 ) . Conclusion . Among the general population , neck pain persists at 12 months in around half of those who report neck pain at the start of the period . An increased risk of persistent neck pain was associated with age 45 to 59 years and low back pain , and also with cycling . The linkwith psychological distress and the absence of a link with occupational factors compares with other previous findings for common musculoskeletal syndromes in the community STUDY DESIGN A prospect i ve population -based cohort study performed in South Manchester , United Kingdom . OBJECTIVES To determine whether nonoccupational physical activity and indicators of physical stress on the spine predict low back pain in the short term . SUMMARY OF BACKGROUND DATA There is evidence that physical activity outside the workplace helps to protect against low back pain in the long term . However , such activity may injure or stress the spine in the short term . METHODS A baseline survey question naire identified 2715 adults , aged 18 - 75 years , with no low back pain at the time of the survey . Information on potential predictors of low back pain also was obtained . New episodes of back pain were identified during the subsequent year . RESULTS A new low back pain episode occurred in 34 % of men and 37 % of women . Poor general health at baseline was the strongest predictor of a new episode of pain ( men : relative risk ( RR ) 1.5 , 95 % confidence intervals ( CI ) 0.8 , 2.7 ; women : RR 2.2 , 95 % CI 1.2 , 4.0 ) . High weight was associated with subsequent low back pain in women ( RR 1.4 ; 95 % CI 1.0 , 2.0 ) , but neither height nor weight predicted low back pain in men . A self-rated low level of physical activity  was not consistently linked with subsequent low back pain , nor were specific nonoccupational physical activities , apart from home-improvement work in men and regular sports in women . CONCLUSION Although some specific activities may be hazardous to the back , physical activity outside the workplace does not increase the short-term risk of low back pain overall . Leisure-time physical activity is not a hazard to the back , whereas poor physical health in both genders and heavier weight in women do increase the risk of new low back pain episodes in the short term Background Musculoskeletal complaints have a significant impact on work in terms of reduced productivity , sickness absence and long term incapacity for work . This study sought to explore GPs ’ and physiotherapists ’ perceptions of  sickness certification in patients with musculoskeletal problems . Methods Eleven ( 11 ) GPs were sample d from an existing general practice survey , and six ( 6 ) physiotherapists were selected r and omly using ‘ snowball ’ sampling techniques , through established contacts in local physiotherapy departments .  Semi-structured qualitative interviews were conducted with respondents lasting up to 30 minutes . The interviews were audio recorded and transcribed verbatim , following which they were coded using N-Vivo qualitative software and analysed thematically using the constant comparative methodology , where themes were identified and contrasted between and within both groups of respondents . Results Three themes were identified from the analysis : 1 ) Approaches to evaluating patients ’ work problems 2 ) Perceived ability to manage ‘ work and pain ’ , and 3 ) Policies and penalties in the work-place . First , physiotherapists routinely asked patients about their job and work difficulties using a structured ( protocol -driven ) approach , whilst GPs rarely used such structured measures and were less likely to enquire about patients ’ work situation . Second , return to work assessment s revealed a tension between GPs ’ gatekeeper and patient advocacy roles , often resolved in favour of patients ’ concerns and needs . Some physiotherapists perceived that GPs ’ decisions could be influenced by patients ’ dem and for a sick certificate and their close relationship with patients made them vulnerable to manipulation . Third , the workplace was considered to be a specific source of strain for patients acting as a barrier to work resumption , and over which GPs and physiotherapists could exercise only limited control . Conclusion We conclude that healthcare professionals need to take account of patients ’ work difficulties , their own perceived ability to offer effective guidance , and consider the ‘ receptivity ’ of employment context s to patients ’ work problems , in order to ensure a smooth transition back to work Objective : This article examines the effectiveness of manual therapy with specific adjuvant exercise for treating  chronic low back pain and disability .  Methods : A single blind , r and omized , controlled trial was employed . Patients were prescribed an exercise program that was tailored to treat their musculoskeletal dysfunctions or given a nonspecific program of general stretching and aerobic conditioning . In addition , patients received manual therapy or sham manual therapy . Participants were seen for 6 weekly sessions and were asked to perform their exercise program twice daily . Results : Seventy-two out of 100 patients completed the study . Multivariate tests conducted for measures of pain and disability revealed a significant group by time interaction ( P = 0.04 and P = 0.05 , respectively ) , indicating differential change in these measures pretreatment to posttreatment as a function of the treatment received . When controlling for pretreatment scores , patients receiving manual therapy with specific adjuvant exercise reported significant reductions in pain . No change in perceived disability was observed , with the exception that patients receiving sham manual therapy with specific adjuvant exercise reported significantly greater disability at posttreatment . Discussion : Manual therapy with specific adjuvant exercise appears to be beneficial in treating  chronic low back pain .  Despite changes in pain , perceived function did not improve . It is possible that impacting chronic low back pain alone does not address psychosocial or other factors that may contribute to disability . Further studies are needed to examine the long-term effects of these interventions and to address what adjuncts are beneficial in improving function in this population Study Design . A r and omized clinical trial with blinded assessment . Objectives . To investigate the clinical efficacy of 2 active interventions for patients with chronic low back pain . Summary of Background Data . Manual therapy and exercise prescription are treatments frequently prescribed for patients with chronic low back pain . The evidence for the relative benefit of these treatments is limited , and questions concerning the most appropriate type of intervention remain unanswered . Methods . Eighty patients with chronic low back pain ( > 3 months ) were r and omized to one of the following treatments , involving 8 treatments over 8 weeks ; 1 ) one-to-one treatment involving 30 minutes of manual therapy ( mobilizations to the spine ) and spinal stabilization exercises , and 2 ) a 10 station exercise class involving aerobic exercises , spinal stabilization exercises , and manual therapy . Three physiotherapists led the hour long group with a maximum of 10 patients . Question naires were completed , and physical measurements were taken by a blinded observer before r and omization , at the completion of treatment , and at 6 months and 12 months after the completion of treatment . The intention-to-treat principle was used in data analysis . Results . Eleven patients dropped out of the individual treatment sessions and 7 dropped out of the exercise group . There was a significant reduction ( reduced disability ) in the question naire score in both groups , and there were significant increases in range for all the physical movements tested in both groups . The exercise group was 40 % more cost effective than the individual treatments . Conclusion . Both forms of intervention were associated with significant improvement . On-going clinical research is necessary to provide guidance as to the clinical efficacy of various forms of intervention Abstract Objective : To evaluate the effectiveness of combinations of three methods to promote physical activity . Design : R and omised controlled trial . Baseline assessment with post-intervention follow up at 12 weeks and 1 year . Setting : One urban general practice , 1995 - 7 . Participants : 523 adults aged 40 to 64 years , r and omised to four intervention groups and a control group . Interventions : Brief ( one interview ) or intensive ( six interviews over 12 weeks ) motivational interviewing based on the stages of change model of behaviour change , with or without financial incentive ( 30 vouchers entitling free access to leisure facilities ) . Main outcome measures : Physical activity score ; sessions of moderate and vigorous activity in the preceding four weeks . Results : Response rate was 81 % at 12 weeks and 85 % at one year . More participants in the intervention group reported increased physical activity scores at 12 weeks than controls ( 38 % v 16 % , difference 22 % , 95 % confidence interval for difference 13 % to 32 % ) , with a 55 % increase observed in those offered six interviews plus vouchers . Vigorous activity increased in 29 % of intervention participants and 11 % of controls ( difference 18 % , 10 % to 26 % ) , but differences between the intervention groups were not significant . Short term increases in activity were not sustained , regardless of intensity of intervention . Conclusions : The most effective intervention for promoting adoption of exercise was the most intensive . Even this did not promote long term adherence to exercise . Brief interventions promoting physical activity that are used by many schemes in the United Kingdom are of question able effectiveness . Key messages Schemes promoting physical activity are currently popular in general practice in Britain , but few have been rigorously evaluated and their effectiveness is unknown . In this study , the most effective intervention for promoting adoption of physical activity was the most intensive , involving six motivational interviews and a financial incentive A comparatively brief intervention ( one interview ) was only effective in the short term in around a third of participants Short term increases in physical activity were not maintained at one year follow up and even the most intensive intervention was ineffective in promoting long term adherence to increased physical activity . National and local government , health authorities , and primary healthcare teams should be cautious about current and future expenditure on , and implementation of , exercise prescription or referral BACKGROUND Studies have shown the effectiveness of a few weekly pilates sessions as helping to reduce lower back pain ( LBP ) . However many patients fear that physical activity can actually make the pain and disability worse . DESIGN We carried out this observational prospect i ve clinical study to look at the effects that taking part in daily pilates has one on side and on the other the effects of LBP management without physical exercise . SETTING The volunteers who participated in this study were recruited from among some local cultural associations . POPULATION Patients affected by LBP were evaluated . METHODS The subjects were 60 volunteers ( 27 males and 33 females ) with a mean age of 51.2 years who had chronic low back pain ( CLBP ) . They were allocated to pilates group ( N.=30 ) or inactivity control group ( N.=30 ) . The pilates group performed one-hour lesson of pilates exercise , 5 lessons per week during the following 6 months . The inactivity group continued with their normal daily activities . The Rol and -Morris Disability , the Oswestry , the SF-36 and the Spinal Functional Sort Question aries of all subjects were measured at the baseline ( T1 ) and at 6 months ( T2 ) . RESULTS At T2 improvements were observed in the pilates group with increases in physical and social functioning , general health and vitality ( P<0.05 ) and decreases in disability and pain ( P<0.05 ) . The inactivity group showed worsening in the same measures at T2 . CONCLUSION We found an important improvement of pain , disability and physical and psychological perception of health in individuals who did the daily sessions of pilates . CLINICAL REHABILITATION IMPACT Some authors underlined the possible risk of a lack of adherence to an exercise program at home . This study suggests that a daily pilates program is effective for the management of CLBP . On the other h and , the inactivity contributes to further worsening , inducing a vicious cycle in which pain and physical activity intolerance follow each other Objective : To investigate the effect of two contrasting physical activity worksite interventions versus a reference intervention ( REF ) on various health outcomes . Methods : A 1-year r and omized controlled trial was conducted with specific resistance training ( SRT ) , all-round physical exercise ( APE ) , and REF . Results : SRT and APE compared with REF showed significant reductions in systolic blood pressure ( ∼6 mm Hg ) , body fat percentage ( ∼2.2 body fat% ) , as well as shoulder and back pain ( ∼30 % reduction in duration ) . Muscle strength ( APE and SRT ) and maximal oxygen uptake ( APE ) increased approximately 10 % . Conclusions : Worksite intervention with both SRT as well as APE is recommended , since these activities compared with REF result ed in clinical ly relevant reductions of cardiovascular and metabolic syndrome-related risk factors as well as musculoskeletal pain symptoms , in combination with minor increases in physical capacity Knee osteoarthritis is a major age-related public health problem and a leading cause of long-term pain and disability ( 1 , 2 ) . No effective medical treatments for the disease currently exist . Nonsteroidal anti-inflammatory drugs ( NSAIDs ) and acetaminophen are commonly used to treat osteoarthritis but often fail to relieve symptoms and may cause serious adverse effects ( 3 ) . Physical therapy , a globally recommended element of the st and ard care regimen for knee osteoarthritis , produces moderate benefits for pain and physical functioning , but data on psychological well-being and durability effects are limited ( 4 , 5 ) . Identifying new and effective treatments for patients with knee osteoarthritis is an urgent clinical and public health priority . Tai Chi is a multicomponent traditional Chinese mindbody practice that combines meditation with slow , gentle , graceful movements ; deep diaphragmatic breathing ; and relaxation ( 6 ) . Previous studies have indicated that Tai Chi can reduce pain and improve physical and psychological health among patients with chronic rheumatic disorders , such as rheumatoid arthritis and fibromyalgia ( 713 ) . In our previous r and omized trial , participants with knee osteoarthritis who completed 12 weeks of  Tai Chi showed greater improvements in pain , physical function , depression , and health status compared with an attention control group ( 12 ) . A 2013 up date d meta- analysis of 7 studies that included 348 participants with osteoarthritis showed significant reductions in pain and improvements in physical function after 8 to 24 weeks of Tai Chi training compared with a waiting list , attention control , or usual physical activity ( 14 ) . Those prior trials suggested that Tai Chi could provide a practical exercise regimen with an integrative mindbody approach to manage knee osteoarthritis . The physical component provides exercise benefits that are consistent with recommendations for knee osteoarthritis ( physical function , balance , and muscle strength ) ( 15 ) , and the mind component promotes psychological well-being , life satisfaction , and improved perceptions of health ( 9 , 16 ) . To date , however , no r and omized trials have directly compared Tai Chi and st and ard care treatments . The primary goal of this study was to compare the effectiveness of  Tai Chi  versus a physical therapy regimen among a large sample of patients with symptomatic and radiographic knee osteoarthritis who were seen in the clinical setting and followed for 12 months . Supplement . Study Protocol Methods Design Overview This 52-week , single-blind , r and omized , comparative effectiveness trial recruited participants with symptomatic and radiographic knee osteoarthritis . Patients were r and omly assigned to either Tai Chi ( 2 times per week for 12 weeks ) or physical therapy in a clinical setting ( 2 times per week for 6 weeks , followed by 6 weeks of rigorously monitored home exercise ) . Details of the trial design and conduct have been published ( 17 ) and registered at Clinical Trials.gov ( NCT01258985 ) . The study was approved by the Tufts Health Sciences Institutional Review Board and overseen by an independent data and safety monitoring board . Setting and Participants The trial was conducted at Tufts Medical Center in Boston , Massachusetts , between October 2010 and September 2014 . Participants were recruited through multimodal strategies , including print advertisements , online media , a booth at a senior exposition , and a clinical patient data base . We obtained informed consent before baseline assessment s for eligibility . We enrolled persons aged 40 years or older who met American College of Rheumatology criteria for symptomatic knee osteoarthritis and had radiographic evidence of tibiofemoral or patellofemoral osteoarthritis ( defined as the presence of a definite osteophyte in the tibiofemoral compartment and /or the patellofemoral compartment , as assessed on st and ing anteriorposterior and lateral or sunrise views ) ( 18 ) . All participants were required to have a score of 40 or greater on at least 1 of the 5 questions in the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) pain subscale ( range of 0 to 100 , with higher scores indicating greater pain ) at baseline . A study rheumatologist ( W.H. ) confirmed eligibility of applicants . We excluded persons who had participated in Tai Chi or physical therapy in the past year ; those with current serious medical conditions , such as dementia , symptomatic heart or vascular disease , or recent stroke , that would limit full participation ; those with intra-articular steroid or intra-articular hyaluronic acid injections in the past 3 or 6 months or reconstructive surgery before baseline screening on the most severely affected knee ; and those with a score less than 24 on the Mini-Mental State Examination ( 19 ) . Participants who satisfied eligibility criteria were offered enrollment . R and omization Participants were r and omly assigned in a 1:1 ratio to Tai Chi or physical therapy after the baseline evaluation . R and omization was done in 9 consecutive cycles , comprising about 20 participants each . Within each block of patients r and omly assigned in each cycle , those assigned to Tai Chi were further r and omly assigned to 1 of 3 instructors so that each instructor treated 1 group every 3 blocks . This design allowed for assessment of instructor-level effects . Pseudor and om numbers were generated in advance by the statistician ( C.S. ) using the R statistical package ( 20 ) . Assignments were concealed in sealed , opaque envelopes with date and signature labels . The study coordinator opened the consecutive envelopes individually after obtaining consent and confirming eligibility . Research study nurses , physical function assessors , and sponsor personnel were blinded to the treatment assignments during enrollment . The blinded assessors did not have access to the data until data collection was complete . Interventions Tai Chi and physical therapy ran concurrently to minimize seasonal influences on disease activity . We encouraged participants to maintain routine activities but refrain from new exercises outside the study . Both groups received educational information about the importance of physical activity and home practice . We tracked reasons for missed sessions and asked participants to complete daily logs indicating duration of practice . Participants were encouraged to integrate at least 30 minutes of Tai Chi or physical therapy into their daily routine throughout follow-up . Attendance was monitored during each in-person session by using attendance forms and sign-in sheets . Study staff made monthly calls to monitor adherence throughout the 1-year follow-up . Tai Chi The 60-minute Tai Chi sessions occurred twice per week for 12 weeks . We recruited 3 experienced Tai Chi instructors from the greater Boston area . We developed a st and ardized classical Yang style Tai Chi protocol for knee osteoarthritis that was based on the literature ( 13 ) . Before study initiation , the principal investigator ( C.W. ) and the Tai Chi master ( R.R. , who was also 1 of the 3 instructors ) review ed the concepts of knee osteoarthritis and trained the other instructors ( 17 , 21 ) . In the first session , participants received printed material s on  Tai Chi principles , practice techniques , and safety pre caution s. The instructor explained mindbody exercise theory and procedures . Subsequent sessions started with a warm-up and a review of Tai Chi principles and movement , breathing techniques , and relaxation methods . Participants were instructed to practice Tai Chi at home for at least 20 minutes per day . The principal investigator monitored all sessions by regularly review ing video recordings and providing feedback throughout the study . After completing the 12-week intervention ( 24 sessions ) , participants were instructed to continue Tai Chi practice for 52 weeks with the aid of provided homework material s. Physical Therapy The physical therapy protocol followed U.S. guidelines for knee osteoarthritis treatment ( 15 ) and consisted of two 30-minute outpatient sessions per week for 6 weeks . Before enrollment , the supervising physical therapist ( M.I. ) trained the 3 physical therapists . She observed evaluations and interventions during each treatment cycle to ensure consistency in documentation and provided feedback for program progression ( 17 ) . Depending on the diagnostic findings in the initial musculoskeletal examination , the therapist targeted physical therapy regimens to address specific treatment goals developed collaboratively with the participant . At each session , the physical therapist examined the participant for adverse signs and symptoms before proceeding with manual therapy or exercise . Patients were encouraged to also perform exercises at home . After 6 weeks , participants were instructed to continue exercises in 30-minute sessions 4 times per week for 6 weeks . These were monitored weekly by telephone by using st and ardized forms to ascertain frequency , exercises completed , adverse events , and adherence . Outcomes and Follow-up Knee osteoarthritis outcomes , which were measured at baseline and 12 , 24 , and 52 weeks , were drawn from the core set recommended by the Osteoarthritis Research Society International ( OARSI ) and focused on pain , physical function , and patients ' overall assessment of their disease severity ( 22 ) . Primary Outcome The primary outcome was the change in WOMAC pain subscale score between baseline and 12 weeks . The WOMAC is a vali date d , self-administered visual analogue scale design ed specifically to evaluate osteoarthritis symptoms ( 23 ) . Secondary Outcomes Secondary outcomes were measured at baseline and 12 , 24 , and 52 weeks and included WOMAC physical function and stiffness scores , Patient Global Assessment score , Beck Depression Inventory-II score ( 24 ) , scores on the physical and mental components of the 36-item Short Form Health Survey ( SF-36 ) ( 25 ) , Arthritis Self-Efficacy Scale score ( 26 ) , and results of the 6-minute walk test ( 27 ) and the The authors sought to determine the analgesic activity of clomipramine ( CMP ) versus placebo , efficacy and side-effects according to the time of administration , long term clinical results and the relationship between plasma levels and analgesic effect . This double-blind r and omised trial involved the infusion of 250 ml of glucose solution morning and evening versus placebo . CMP was administered at progressive doses for 8 days ( maximum dosage 75 mg ) , either in the morning at 8 a.m. or in the evening at 6 p.m. Sixty eight patients accepted to be treated , all suffering from low back pain with or without sciatica . Maintenance treatment at the dose of 75 mg/day was then administered . CMP had a statistically significant analgesic action independent ( rapidity of action ) of its antidepressant activity . CMP was more effective and better tolerated ( sedative and tranquilizer effect ) in the evening . Long term results were poor ( 75 % of cases ) . There was no link between plasma levels and clinical response . The authors noted that the analgesic activity of CMP was rapid , but for a duration limited to the short term and that this efficacy compared with the quite good results obtained with the placebo could be explained by a possible method ological bias ( patients hospitalised and treated by intravenous infusions ) . The finding that CMP was better tolerated in the evening , without any loss of efficacy , is a positive feature ( chronotherapeutic trial ) . Poor long term results could be partially explained by side-effects ( 66 % ) . There was no relationship between analgesic effect and plasma levels This study examined long-term effects of a tailored behavioural treatment protocol ( TBT ) , as compared with an exercise based physical therapy protocol ( EBT ) .  One-hundred and twenty-two patients who , due to persistent musculoskeletal pain , consulted physical therapists in primary care were originally r and omized to either of the two conditions . Follow-up assessment s two-year post-treatment were completed by 65 participants . According to per- protocol analyses , short-term effects were maintained in both groups for the primary outcome , pain-related disability . The TBT-group reported lower disability levels compared with the EBT-group . Intention-to-treat analyses ( ITT ) conveyed similar results . Secondary outcomes of pain intensity , pain control , and functional self-efficacy were maintained over the 2-year post-treatment , but previous group differences were levelled out according to the most conservative method of ITT . Fear of movement/(re)injury increased in the EBT-group , and EBT participants reported higher fear of movement/(re)injury two years post-treatment compared to TBT . The study supports tailoring of treatments in concordance with patients ' needs and preferences of activity goals and functional behavioural analyses including predictors of pain-related disability , for successful immediate outcomes and their maintenance in the long run . Exercise-based treatments result ed in somewhat smaller immediate treatment effects but had similar maintenance of effects over the 2-year follow-up period Loss of function and low exercise adherence is common among older people after hospitalization . The aim of this r and omized-controlled trial was to evaluate the effects of a combined counseling- and exercise program on changes in health-related quality of life ( HRQL ) and physical function in patients attending a day hospital and continuing exercise at home . The exercise program consisted of counseling , balance- and progressive resistance training and support from the physical therapist at Geriatric Day-Hospital ( GDH ) and home for the Intervention-group . The  Control-group received counseling , balance-training and support from the physical therapist .  The sample was recruited from a GDH in Norway . 108 participants were r and omized into the Intervention group ( IT ) ( n=53 ) or the Control group ( CT ) ( n=55 ) . After 3 months 77 participants were tested . The intention to treat analysis showed that the program had significant benefits in terms of Health Related Quality of Life , measured by SF-36 , on the domains vitality and bodily pain , in favor of the IT-group who performed the combined resistance exercises and balance program . All participants increased their scores on physical function , measured by Berg Balance Scale , Timed Up and Go , 5 times Sit-to-St and , 6 Min Walk Test and Activities Balance Confidence Scale , no group differences . Both groups were adherent to the  home exercise program The results show that it is possible to facilitate older people to increase their HRQL , physical function and level of physical activity through counseling , exercise and support from physical therapists Background Exercise benefits patients with chronic nonspecific low back pain ; however , the most effective type of exercise remains unknown . Objective This study compared outcomes after motor control exercises , sling exercises , and general exercises for low back pain . Design This was a r and omized controlled trial with a 1-year follow-up . Setting The study was conducted in a primary care setting in Norway . Patients The participants were patients with chronic nonspecific low back pain ( n=109 ) . Interventions The interventions in this study were low-load motor control exercises , high-load sling exercises , or general exercises , all delivered by experienced physical therapists , once a week for 8 weeks . Measurements The primary outcome measure was pain reported on the Numeric Pain Rating Scale after treatment and at a 1-year follow-up . Secondary outcome measures were self-reported activity limitation ( assessed with the Oswestry Disability Index ) , clinical ly examined function ( assessed with the Fingertip-to-Floor Test ) , and fear-avoidance beliefs after intervention . Results The postintervention assessment showed no significant differences among groups with respect to pain ( overall group difference ) or any of the outcome measures . Mean ( 95 % confidence interval ) group differences for pain reduction after treatment and after 1 year were 0.3 ( −0.7 to 1.3 ) and 0.4 ( −0.7 to 1.4 ) for motor control exercises versus sling exercises , 0.7 ( −0.6 to 2.0 ) and 0.3 ( −0.8 to 1.4 ) for sling exercises versus general exercises , and 1.0 ( −0.1 to 2.0 ) and 0.7 ( −0.3 to 1.7 ) for motor control exercises versus general exercises . Limitations The nature of the interventions made blinding impossible . Conclusions This study gave no evidence that 8 treatments with individually instructed motor control exercises or sling exercises were superior to general exercises for chronic low back pain [ Purpose ] Nonspecific low back pain ( NSLBP ) is a very common but largely self-limiting condition . Several types of tape and their associated application methods are available for different conditions . The aim of the present study was to observe the effect of Kinesio taping ( KT ) compared with traditional management of NSLBP . [ Subjects and Methods ] Forty male and female patients with a mean age of 34.8±7.54 years were r and omly divided into two groups ; group 1 ( n=20 ) which underwent conventional physical therapy with KT , and group 2 ( n=20 ) , which underwent only conventional physical therapy . The intervention sessions for both groups were three times per week for four weeks . Outcomes were assessed for activities of daily living ( ADL ) using the Rol and -Morris Disability Question naire , pain severity using a visual analogue scale , and ranges of motion ( ROMs ) of trunk flexion and extension using the modified Schober ’s test . [ Results ] Significant differences in measures of pain , ADL , and trunk flexion and extension ROMs were observed post intervention within each group . In comparison , there were no significant differences in measures of pain , ADL , and trunk flexion and extension ROMs post intervention between groups . [ Conclusion ] A physical therapy program involving strengthening exercises for abdominal muscles and stretching exercises for back , hamstring , and iliopsoas muscles with or without Kinesio taping was beneficial in the treatment of chronic low back pain Background : The treatment of exercise-related injuries is often a problem , and recurrent injuries are common . Two recent systematic review s found only one high- quality paper on the treatment of long-st and ing groin pain .  In this r and omized clinical trial , a training program including strength training result ed in a return of 79 % of the athletes to the previous level of sport without any groin pain . The long-term effect of this exercise program was evaluated . Hypothesis : The effect of the exercise program for adductor-related groin pain is long lasting . Study Design : R and omized controlled trial ; Level of evidence , 1 . Methods : Forty-seven ( 80 % ) of the 59 original participants of the study agreed to participate in this 8- to 12-year follow-up . They were all interviewed and examined using a st and ardized and reproducible protocol , identical to the one used in the original trial . The investigating physician ( P.N. ) was not involved in the original study and was unaware of the original treatment allocation . Results : A significant effect of the active training treatment  still existed for the whole group ( P = .047 ) and even more for the subgroup of 39 ( 83 % ) soccer players ( P = .012 ) . No significant differences were found regarding age , present sports activity , reasons for activity reduction , or time to follow-up . Conclusion : The beneficial short-term effect of the exercise program used in the primary r and omized clinical trial for treating long-st and ing adductor-related groin pain in athletes was found to be lasting , both for the whole group and even more for the large subgroup of soccer players . This is the first time an exercise treatment for overuse injuries to the musculoskeletal system has been shown to have a long-lasting effect ( 8 - 12 years ) Background Evidence supports the use of exercise for chronic low back pain ( CLBP ) ; however , adherence is often poor due to ongoing pain . Auricular acupuncture is a form of pain relief involving the stimulation of points on the outer ear corresponding with specific body parts . It may be a useful adjunct to exercise in managing CLBP ; however , there is only limited evidence to support its use with this patient group . Methods / Design This study was design ed to test the feasibility of an assessor-blind r and omised controlled trial which assess the effects on clinical outcomes and exercise adherence of adding manual auricular acupuncture to a personalised and supervised exercise programme ( PEP ) for CLBP . No sample size calculation has been carried out as this study aims to identify CLBP referral rates within the catchment area of the study site . The research ers aim to recruit four cohorts of n = 20 participants to facilitate a power analysis for a future r and omised controlled trial . A computer generated r and om allocation sequence will be prepared central ly and used to allocate participants by cohort to one of the following interventions : 1 ) six weeks of PEP plus manual auricular acupuncture ; 2 ) six weeks of PEP alone . Both groups will also complete a further six weeks of self-paced exercise with telephone follow-up support . In addition to a baseline and exit question naire at the beginning and end of the study , the following outcomes will be collected at baseline , and after 7 , 13 and 25 weeks : pain frequency and bothersomeness , back-specific function , objective assessment and recall of physical activity , use of analgesia , perceived self-efficacy , fear avoidance beliefs , and beliefs about the consequences of back pain . Since this is a feasibility study , significance tests will not be presented , and treatment effects will be represented by point estimates and confidence intervals . For each outcome variable , analysis of covariance will be performed on the data , conditioning on the baseline value . Discussion The results of this study investigating the adjuvant effects of auricular acupuncture to exercise in managing CLBP will be used to inform the design of a future multi-centre r and omised controlled trial . Trial Registration Current Controlled Trials IS RCT N94142364 Background Current evidence supports the use of exercise-based treatment for chronic low back pain that encourages the patient to assume an active role in their recovery . Walking has been shown it to be an acceptable type of exercise with a low risk of injury . However , it is not known whether structured physical activity programmes are any more effective than giving advice to remain active . Methods / Design The proposed study will test the feasibility of using a pedometer-driven walking programme , as an adjunct to a st and ard education and advice session in participants with chronic low back pain . Fifty adult participants will be recruited via a number of different sources . Baseline outcome measures including self reported function ; objective physical activity levels ; fear-avoidance beliefs and health-related quality of life will be recorded . Eligible participants will be r and omly allocated under strict , double blind conditions to one of two treatments groups . Participants in group A will receive a single education and advice session with a physiotherapist based on the content of the ' Back Book ' . Participants in group B will receive the same education and advice session . In addition , they will also receive a grade d pedometer-driven walking programme prescribed by the physiotherapist . Follow up outcomes will be recorded by the same research er , who will remain blinded to group allocation , at eight weeks and six months post r and omisation . A qualitative exploration of participants ' perception of walking will also be examined by use of focus groups at the end of the intervention . As a feasibility study , treatment effects will be represented by point estimates and confidence intervals . The assessment of participant satisfaction will be tabulated , as will adherence levels and any recorded difficulties or adverse events experienced by the participants or therapists . This information will be used to modify the planned interventions to be used in a larger r and omised controlled trial . Discussion This paper describes the rationale and design of a study which will test the feasibility of using a structured , pedometer-driven walking programme in participants with chronic low back pain . Trial Registration [ IS RCT N67030896 BACKGROUND Recent guidelines for those with acute low back pain have advocated early resumption of normal activity and increased physical activity . Little is known about the relationship between low back pain and physical activity , and on the impact of that relationship on the promotion of increased levels of physical activity within a general practice population . OBJECTIVES We aim ed to explore associations between factors that influence changes in physical activity and the way individuals perceive and behave with their low back pain , and the impact of those perceptions and behaviour on physical activity . METHODS Twenty-seven informants were chosen using a purposive sample from a larger group of individuals who , because of their low back trouble , had been referred by their GPs to a community-based , single-blind , r and omized controlled trial ( RCT ) at the University of York , which is evaluating the effectiveness and cost-effectiveness of a progressive exercise programme . Fifty-four interviews were conducted with this subgroup of the RCT ; four informants were interviewed once , 19 twice and four of them three times . Interviews were transcribed and analysed using manual and computer-aided approaches . RESULTS Physical activity was perceived as ( i ) activities of daily living , ( ii ) activities causing breathlessness that they went out of the way to do and ( iii ) more competitive-type activity . The avoidance of physical activity and fear of pain returning were the two main factors directly associated with informants ' backs and changes in physical activity . These two factors hindered increases in physical activity , even though the majority of informants believed strongly that being physically active helped ease their low back pain . CONCLUSIONS When advocating that individuals with acute low back pain return to or increase physical activity , it is important that clinicians identify avoidance of physical activity and /or fear of pain at the earliest stage in order to tailor advice and reassurance appropriately . If avoidance of activity and fear of pain is identified and clinicians want to encourage patients to take up and sustain increased physical activity , they should explore issues of fear of pain , and avoidance of and confidence to do physical activities , in addition to other factors influencing physical activity BACKGROUND Better insight into frequent comorbidities in patients with chronic ( ≥ 3 months ) low back pain ( LBP ) may help general practitioners when planning comprehensive care for these patients . OBJECTIVE To prospect ively study the prevalence of psychological , social , musculoskeletal and somatoform disorders in patients presenting with chronic non-specific LBP to general practitioners , in comparison to a contrast group of patients consulting in the same setting . METHODS This case-control study is embedded in a historical cohort , based on a primary care practice -based research network . All the health problems presented by the patients were prospect ively coded according to the international classification of primary care between 1996 and 2013 . The prevalence of psychological , social , musculoskeletal and somatoform disorders presented by the adult patients from 1 year before the onset of chronic LBP to 2 years after onset was compared to that of matched patients consulting without LBP , using conditional logistic regressions . RESULTS The 1511 patients with chronic LBP more often presented musculoskeletal disorders than the contrast group during the year before the onset of LBP and during the second year after it , with odds ratios ( 95%confidence intervals ) of 1.39 ( 1.20 - 1.61 ) and 1.56 ( 1.35 - 1.81 ) , respectively . They did not more often present psychological , social or non-musculoskeletal somatoform disorders . CONCLUSIONS General practitioners should consider all the musculoskeletal symptoms when caring for patients with chronic LBP . Rather than systematic ally screening for specific psychological , social or somatoform disorders , they should consider with the patient how LBP and any type of potential comorbidity interfere with his/her daily functioning The effects of exercise for isolated lumbar extensor muscles were examined in 54 chronic low-back pain patients . Subjects were r and omly assigned to a 10-week exercise program ( N = 31 ) or a wait-list control group ( N = 23 ) . Results indicated a significant increase in isometric lumbar extension strength for the treatment group and a significant reduction in reported pain compared with the control group ( P 0.05 ) . Treated subjects reported less physical and psychosocial dysfunction whereas the control group increased in pain , and physical and psychosocial dysfunction . There were no concomitant changes in reported daily activity levels . These results show that lumbar extension exercise is beneficial for strengthening the lumbar extensors and results in decreased pain and improved perceptions of physical and psychosocial functioning in chronic back pain patients . However , these improvements were not related to changes in activities or psychological distress QUESTION Does behavioural grade d activity result in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hip or knee ? DESIGN Analysis of secondary outcomes of a cluster-r and omised trial with concealed allocation , assessor blinding , and intention-to-treat analysis . PARTICIPANTS Two hundred patients with hip and /or knee osteoarthritis . INTERVENTION Experimental group received 18 sessions of behavioural grade d activity over 12 weeks and up to 7 booster sessions over the next year . The control group received 18 sessions of usual care over 12 weeks according to the Dutch physiotherapy guideline . OUTCOME MEASURES Exercise adherence was measured using a question naire and physical activity was measured using the SQUASH question naire at baseline , 13 , and 65 weeks . RESULTS Adherence to recommended exercises was significantly higher in the experimental group than in the control group at 13 weeks ( OR 4.3 , 95 % CI 2.1 to 9.0 ) and at 65 weeks ( OR 3.0 , 95 % CI 1.5 to 6.0 ) . Significantly more of the experimental than the control group met the recommendations for physical activity at 13 weeks ( OR 5.3 , 95 % CI 1.9 to 14.8 ) and at 65 weeks ( OR 2.9 , 95 % CI 1.2 to 6.7 ) . CONCLUSION Behavioural grade d activity results in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hip or knee , both in the short- and long-term . TRIAL REGISTRATION NCT00522106 Study Design . Cluster r and omized controlled trial for a multifaceted implementation strategy . Objectives . To assess the effectiveness of tailored  interventions ( multifaceted implementation strategy ) to implement the  Dutch low back pain guideline for general practitioners with regard to adherence to guideline recommendations . Summary of Background Data . Guidelines for the management of low back pain in primary care have been developed in various countries , but little is known about the optimal implementation strategy . A multifaceted implementation strategy was developed to overcome identified barriers to the implementation of the Dutch low back pain guideline for general practitioners . Methods . General practitioners were r and omized to an intervention or a control group . The general practitioners in the intervention group ( n = 21 ) received tailored interventions consisting of the Dutch low back pain guideline for general practitioners , a 2-hour educational and clinical practice workshop ; two scientific articles on low back pain management ; the guideline for occupational physicians ; a tool for patient education ; and a tool for reaching agreement on low back care with physical , exercise , and manual therapists . The control group ( n = 20 ) received no intervention . The participating general practitioners were asked to recruit consecutive patients with a new episode of low back pain as the main reason for consultation . General practitioners completed registration forms of each individual consultation with regard to the main outcome measures : advice and information , referral to other health-care providers , and prescription of medication . Results . Forty-one of the 67 r and omized general practitioners reported on a total of 616 consultations for 531 patients with nonspecific low back pain . The advice and explanation provided by the general practitioners , the prescription of paracetamol or nonsteroidal anti-inflammatory drugs , and prescription of pain medication on atime contingent or a pain contingent basis showed no statistically significant differences between the intervention and control groups . There were also no differences in overall referral rate . However , in follow-up consultations fewer patients were referred to a physical or exercise therapist by the general practitioners in the intervention group than in the control group . Conclusions . The multifaceted intervention strategy modestly improved implementation ( for parts of the recommendations in ) the Dutch low back pain guideline by general practitioners and produced small concomitant changes in patient management . The implementation strategy produced fewer referrals to therapists during follow-up consultations OBJECTIVES The objective of this study is to determine if exercise increases joint symptoms in older adults with a history of arthritis or produces symptoms in older adults without such history . In addition , we examine whether joint symptoms explain the large observed variation in strength gain in older adults undergoing vigorous strength training exercise  , and report the incidence of musculoskeletal injuries upon initiation of an exercise program . DESIGN A population -based , single blinded , r and omized controlled trial with three exercise groups and one control group . SETTING A large urban health maintenance organization . PARTICIPANTS Older men and women ( N = 105 ) aged 68 to 85 , with leg strength below the 50th percentile for their age , sex , height , and weight and without neuromuscular disease or active cardiovascular disease . INTERVENTIONS Supervised exercise in 1-hour sessions , three times each week , for 24 to 26 weeks . One exercise group did strength training ( ST ) using weight machines ( n = 25 ) ; another group did endurance training ( ET ) using stationary cycles ( n = 25 ) ; and the third group did combined strength training and endurance training ( ST+ET ) ( n = 25 ) . The control group ( n = 30 ) received no intervention . MEASUREMENTS Strength was measured at the ankle , knee , hip , and elbow using an isokinetic dynamometer . Joint symptoms were rated on a 6-point scale ( 0 = none , 5 = severe ) . Arthritis severity was based on self-reported use of arthritis medication . Health status was measured with subscales of the SF-36 and Sickness Impact Profile ( SIP ) . RESULTS Joint symptoms fluctuated over time in all exercise groups , but they did not improve or worsen significantly in any group . The physical dimension of the SIP and SF-36 subscale scores , including Bodily Pain Scores , did not change over time in any group . Subjects with arthritis and joint symptoms gained as much strength with strength training as did subjects without joint symptoms . Adjustment for age , gender , baseline strength , adherence , and exercise group did not affect this finding . The rate of minor musculoskeletal injuries was 2.2 injuries per 1000 exercise hours . CONCLUSIONS Moderate intensity stationary cycle exercise and vigorous intensity strength training do not appear to produce or exacerbate joint symptoms in older adults . Joint symptoms did not explain the large variation in gains in strength in older adults participating in a st and ardized strength training exercise program .  Musculoskeletal injuries occurred relatively infrequently , and no major injuries occurred . In evaluating joint pain that occurs in older adults in well regulated exercise programs , clinicians should consider other etiologies before attributing pain to exercise per se Background In the treatment of  chronic back pain  , cognitive methods are attracting increased attention due to evidence of effectiveness similar to that of traditional therapies . The purpose of this study was to compare the effectiveness of performing a cognitive intervention based on a non-injury model with that of a symptom-based physical training method on the outcomes of  low back pain ( LBP ) , activity limitation , LBP attitudes ( fear-avoidance beliefs and back beliefs ) , physical activity levels , sick leave , and quality of life , in chronic LBP patients . Methods The study was a pragmatic , single-blind , r and omised , parallel-group trial . Patients with chronic/recurrent LBP were r and omised to one of the following treatments : 1 . Educational programme : the emphasis was on creating confidence that the back is strong , that loads normally do not cause any damage despite occasional temporary pain , that reducing the focus on the pain might facilitate more natural and less painful movements , and that it is beneficial to stay physically active . 2 . Individual symptom-based physical training programme : directional-preference exercises for those central ising their pain with repetitive movements ; ' stabilising exercises ' for those deemed ' unstable ' based on specific tests ; or intensive dynamic exercises for the remaining patients . Follow-up question naires ( examiner-blinded ) were completed at 2 , 6 and 12 months . The main statistical test was an ANCOVA adjusted for baseline values . Results A total of 207 patients participated with the median age of 39 years ( IQR 33 - 47 ) ; 52 % were female , 105 were r and omised to the educational programme and 102 to the physical training programme .  The two groups were comparable at baseline . For the primary outcome measures , there was a non-significant trend towards activity limitation being reduced mostly in the educational programme group , although of doubtful clinical relevance . Regarding secondary outcomes , improvement in fear-avoidance beliefs was also better in the educational programme group . All other variables were about equally influenced by the two treatments . The median number of treatment sessions was 3 for the educational programme group and 6 for the physical training programme group . Conclusions An educational approach to treatment for chronic LBP result ed in at least as good outcomes as a symptom-based physical training method , despite fewer treatment sessions . Trial registration Clinical trials.gov : # Purpose : To evaluate whether long-term neck and upper body exercises conducted in economical community-based outpatient clinic and home-based setting s could improve health-related quality of life (HRQoL)for  individuals affected by chronic neck pain . The effect of baseline HRQoL and neck pain values on training adherence was also studied . Methods : Subjects ( n = 101 , 91 women/10 men , mean age 41.0 ± 9.5 years ) with chronic non-specific neck pain were r and omized to a combined strength-training and stretching-exercise group ( CSSG , n = 49 ) or to a stretching exercise group ( SG , n = 52 ) . HRQoL was assessed at baseline and after 12 months using the R AND -36 question naire . Comparisons between groups were performed using bootstrap-type analysis of covariance . The impact of HRQoL and neck pain values on training adherence , determined using participants ’ exercise logs , was studied using generalized estimating equations . Results : CSSG showed significant improvements in five and SG in four of eight of the HRQoL dimensions . There were no significant differences between the groups . Adherence to long-term training was only slightly affected by baseline-assessed HRQoL and neck pain values . Conclusions : The two training protocol s were feasible and equally effective in improving HRQoL. Baseline HRQoL and pain values had only a minor effect on training adherence . Implication s for Rehabilitation Long-term strength training and stretching are effective in improving HRQoL in people with chronic neck pain . Baseline HRQoL and neck pain values have little effect on training adherence Conundrums in musculoskeletal research are common . Halliday and colleagues1 demonstrated similar outcomes for patients with chronic low back pain who received two seemingly different interventions : ( 1 ) a McKenzie approach and ( 2 ) motor control exercises .  Chmielewski and associates2 reported similar knee function and psychosocial status scores in those who received either low intensity or high intensity plyometric exercise programmes . Finally , van Beijsterveildt et al found no differences in the prevention of injuries among amateur footballers when usual care was compared against an exercise strategy that consisted of core stability , eccentric training of thigh muscles , proprioceptive training , dynamic stabilisation and plyometrics exercises.3 These findings beg the question : Why do we see similar outcomes in r and omised trials , which compare treatment strategies that are ostensibly different ? Our goal is to provide explanations beyond the obvious answers —such as treatments that have similarly effective or ineffective causal mechanisms or failing to account for patient heterogeneity in trial design and consequent insufficient statistical power to detect differences . In this editorial , we present the reader with four additional yet plausible explanations for why trials report similar outcomes . # # # Reason 1 : the type of outcome assessment may bias findings Our first explanation is the most obvious one . Outcome measures that capture direct measurements of strength and /or flexibility , or other indices of physical performance , may yield findings that are notably different from outcome measures that capture self-reports of pain , function , overall health status or quality of life . Therefore , null findings ( no difference among groups ) may be related to the fact that different sets of outcome measures are being used to compare the groups being studied . Examples of variant findings among outcomes are present in the literature . One month after total hip arthroplasty , Dayton and colleagues4 report that performance-based function ( eg , timed up and go , 6 min walk test and stair climbing test ) declined compared with baseline , whereas self-reported Background and Purpose Given the complex nature of chronic pain , the effects of high-intensity aerobic exercise on pain , disability , psychological strain , and serum cortisol concentrations in people with chronic low back pain were investigated . Subjects Twenty subjects receiving primary health care were r and omly allocated into exercise and control groups . Methods Subjects in the exercise group received a 12-week , high-intensity aerobic exercise program . Subjects in the control group received 12 weeks of passive modalities without any form of physical activity . Results Data analysis identified reductions in pain ( 41 % , t10=8.51 , P<.001 ) , disability ( 31 % , t10=7.32 , P<.001 ) , and psychological strain ( 35 % , t10=7.09 , P<.001 ) in subjects in the exercise group and no changes in subjects in the control group . High-intensity exercise failed to influence serum cortisol concentrations . Discussion and Conclusion Regular high-intensity aerobic exercise alleviated pain , disability , and psychological strain in subjects with chronic low back pain but did not improve serum cortisol concentrations The aim of this analytical cross-sectional study was to evaluate the presence of work-related musculoskeletal disorders ( WMSD ) among dental students in two Brazilian dental schools . The sample included 227 r and omized subjects from fifth to ninth semesters who were developing clinical activities . Each student signed an informed consent form . A self-reporting question naire was used to obtain data on the practice of physical exercise , the presence of pain during or soon after treating patients , and the adoption of preventive measures related to clinical activities . Results were analyzed using the Statistical Package for Social Sciences 13.0 . The chi(2 ) test was used to identify associations between variables . The presence of pain during or after clinical work was reported by 173 participants ( 76.2 percent ) . Statistically significant differences were found between gender and the occurrence of pain . Pain was present during clinical activities ( p=0.006 ) and imposed limitations on the work routine ( p=0.011 ) . Among those who practice d physical exercise , eighty-eight ( 74.6 percent ) reported pain . The high percentage of pain reported by dental students suggests the value of review ing work conditions in dental practice s in order to minimize the exposure of all workers to WMSD OBJECTIVE To examine the prevalence , correlates and prospect i ve impact of musculoskeletal pain on physical and psychological function in a population health survey of elderly Chinese men and women . STUDY DESIGN Cohort study . METHODS Four thous and men and women , aged 65 years and over , living in the community in Hong Kong took part in this study . A question naire to determine demographics , socio-economic status , medical history , smoking , alcohol intake and level of physical activity was administered by an interviewer . Participants were asked about the presence of pain in the back , neck , hip and knee in the past 12 months . They were re-interviewed after 4 years of follow-up to document physical performance measures , psychological function and occurrence of falls , fractures and mortality . RESULTS Overall , back pain was most prevalent ( 48 % ) , followed by knee ( 31 % ) , neck ( 22.5 % ) and hip ( 8.9 % ) pain ; the values was nearly twice as high in women compared with men for all sites . The presence of pain was not correlated with age , but was associated with various measures of socio-economic status as well as comorbidities . Baseline prevalence of pain was related to physical performance and quality -of-life measures , and fracture incidence after 4 years of follow-up . CONCLUSION Musculoskeletal pain is prevalent among elderly men and women , being much higher in the latter , giving rise to considerable functional and psychological impairments . Osteoporosis and osteoarthritis are likely to be the main underlying causes . The condition may be considered part of the frailty syndrome , and in this context , prevention and management represent major public health challenges BACKGROUND Chronic low back pain ( LBP ) accounts for the majority of the disability and costs for LBP . However , the definition of chronicity is unclear . AIM To elicit practitioners ' definitions of chronic LBP patients , both in general and in the patients they were treating ; to assess the most common characteristics of these practitioners ' chronic LBP patients ; and to assess the stability of chronicity in a sample of the general population . METHOD Semi-structured interviews were conducted with 33 practitioners working in private practice , 71 LBP patients and their therapists , and 252 employees of a chain store who were assessed yearly in a prospect i ve study . RESULTS The therapists ' definitions of chronic LBP patients generally included psychosocial aspects . Only physical symptoms and signs were stressed in the patients they were treating . These patients displayed common characteristics with reference to pain , functional problems , and contact with health care services . Duration of symptoms was not sufficient to define chronicity . In the employee population , chronicity defined according to pain duration was unstable . However , the same was true when chronicity was measured according to the criteria defined in the patient population . CONCLUSION There is a discrepancy between theory and practice regarding the definition of chronic LBP . This discrepancy concerns not only the literature but also clinical practice itself . The term ' chronic ' LBP as currently used is therefore equivocal OBJECTIVE To determine whether high exercise adherence improved physical function among older adults with knee osteoarthritis ( OA ) who were overweight or obese . METHODS Associations between  exercise adherence , changes in 6-minute walking distance in meters , and self-reported disability ( Western Ontario and McMaster Universities Osteoarthritis Index function subscale ) after 6 and 18 months were examined among an Arthritis , Diet , and Activity Promotion Trial sub sample ( n = 134 ) using multiple linear regression models . RESULTS Higher exercise adherence was associated with greater improvements in 6-minute walking distance after 6 and 18 months and in disability after 6 months . Pain and body mass index ( BMI ) contributed , to some extent , to explaining the link between exercise adherence  and changes in physical performance and self-reported disability . CONCLUSION Higher exercise adherence is associated with improved physical function in overweight and obese older adults with knee OA . This indicates that promoting adherence is clinical ly relevant when prescribing exercise regimens that also focus on decreasing pain and BMI Objective : To assess health-related quality of life ( HRQOL ) in migraineurs in the general population . Design : Cross-sectional study within the context of a population -based study monitoring health characteristics of the Dutch adult population in two municipalities representative of the general population in the Netherl and s. Migraine was assessed in a multistaged procedure that included a semistructured clinical interview by telephone . Final diagnosis met 1988 International Headache Society criteria . HRQOL was measured with the self-administered R AND 36-item Health Survey ( R AND -36 ) , including physical functioning , social functioning , role limitations , and physical perception . HRQOL of migraineurs was compared with that of nonmigraineurs . To compare and study the effect of comorbidity , the authors also identified subjects with asthma or chronic musculoskeletal pain . There were 5998 people with complete data , 620 of whom had migraine in the last year . Results : Compared with nonmigraineurs , significantly more migraineurs had asthma ( OR = 1.6 ; 95 % CI 1.1 , 2.4 ) or chronic musculoskeletal pain ( OR = 1.7 ; 95 % CI 1.5 , 2.1 ) . Migraineurs reported diminished functioning and well-being on all eight domains as compared with nonmigraineurs . HRQOL was inversely related to attack frequency ( p < 0.0002 ) . Migraineurs had a poorer HRQOL than did those reporting asthma , except for dimensions concerning physical functioning and general health perception , but they had a better HRQOL than did subjects with chronic musculoskeletal pain . Comorbidity of asthma or chronic musculoskeletal pain in migraine further reduced HRQOL . Conclusions : Migraineurs report more asthma and chronic musculoskeletal pain . Compared with nonmigraineurs and to others with chronic conditions , migraineurs report compromised physical , mental , and social functioning , particularly those with a high frequency of attack Background Chronic low back pain remains a major health problem in Australia and around the world . Unfortunately the majority of treatments for this condition produce small effects because not all patients respond to each treatment . It appears that only 25–50 % of patients respond to exercise . The two most popular types of exercise for low back pain are grade d activity and motor control exercises . At present however , there are no guidelines to help clinicians select the best treatment for a patient . As a result , time and money are wasted on treatments which ultimately fail to help the patient . Methods This paper describes the protocol of a r and omised clinical trial comparing the effects of motor control exercises with a grade d activity program in the treatment of chronic non specific low back pain . Further analysis will identify clinical features that may predict a patient 's response to each treatment . One hundred and seventy two participants will be r and omly allocated to receive either a program of motor control exercises or grade d activity . Measures of outcome will be obtained at 2 , 6 and 12 months after r and omisation . The primary outcomes are : pain ( average pain intensity over the last week ) and function ( patient-specific functional scale ) at 2 and 6 months . Potential treatment effect modifiers will be measured at baseline . Discussion This trial will not only evaluate which exercise approach is more effective in general for patients will chronic low back pain , but will also determine which exercise approach is best for an individual patient . Trial registration This study investigated effects of physical exercise on  musculoskeletal pain symptoms in all regions of the body , as well as on other musculoskeletal pain in association with neck pain . A single blind r and omized controlled trial testing a one-year exercise intervention was performed among 549 office workers ;  specific neck/shoulder resistance training , all-round physical exercise , or a reference intervention . Pain symptoms were determined by question naire screening of twelve selected body regions . Case individuals were identified for each body region as those reporting pain intensities at baseline of 3 or more ( scale of 0 - 9 ) during the last three months . For neck cases specifically , the additional number of pain regions was counted . Intensity of pain decreased significantly more in the neck , low back , right elbow and right h and in cases of the two exercise groups compared with the reference group ( P<0.0001 - 0.05 ) . The additional number of pain regions in neck cases decreased in the two exercise groups only ( P<0.01 - 0.05 ) . In individuals with no or minor pain at baseline , development of pain was minor in all three groups . In conclusion , both specific resistance training and all-round physical exercise for office workers caused better effects than a reference intervention in relieving musculoskeletal pain symptoms in exposed regions of the upper body UNLABELLED This study compares the outcomes of an individually tailored behavioral medicine intervention ( experimental ) with physical exercise therapy ( control ) . The experimental intervention was systematic ally individualized according to each participant 's behavioral treatment goals and functional behavioral analyses . One hundred twenty-two patients seeking care at 3 primary health care clinics because of musculoskeletal pain were r and omized . Ninety-seven completed the trial . Data were collected at baseline , immediately after treatment , and at a 3-month follow-up . Analyses of data from completers , as well as intention-to-treat analyses , showed that the experimental group experienced lower levels of disability ( P = .01 ) , lower maximum pain intensity ( P = .02 ) , higher levels of pain control ( P = .001 ) , and lower fear of movement ( P = .022 ) as a result of treatment condition . Self-efficacy ( P = .0001 ) and physical performance ( P = .0001 ) increased over time for both groups . Participants in the experimental group generally reported more positive effects after treatment . Treatment fidelity was maintained during the course of the study . Activity can be resumed and pain might be managed by the patients themselves if treatment incorporates the biopsychosocial explanatory model of pain and strategies are tailored according to individual 's priorities of everyday life activities and empirically derived determinants of pain-related disability . PERSPECTIVE This study shows that the biomedical and the psychosocial perspectives of the experiences and consequences of pain complement rather than contradict each other . Primary health care patients with persistent musculoskeletal pain benefit more from a systematic tailoring of treatments according to biopsychosocial factors than from a physically based exercise intervention & NA ; Current conceptions of chronic pain clearly suggest that proper care at the acute stage should prevent the development of chronic problems . Patients ( 198 ) seeking help for acute musculoskeletal pain ( MSP ) , e.g. , back and neck pain participated in two studies of the effects of an Early Active intervention which underscored ‘ well ’ behavior and function compared to a Treatment as Usual control group . The quantity of the Early Active treatment was a median of 1 doctor 's appointment and 3 meetings with a physical therapist .  Study I concerned patients with a prior history of sick‐listing for MSP , while study II involved patients with no prior history of MSP . Treatment satisfaction , pain experience , activities and sickness absenteeism were assessed before , after and at a 12‐month follow‐up . In study I ( patients with a history of MSP ) , the results showed significant improvements for both groups , but virtually no differences between the groups . Similarly , in study II ( no history of MSP ) both groups demonstrated significant improvements e.g. , for pain intensity and activity levels . However , the Early Active treatment result ed in significantly less sick‐listing relative to the control group . Moreover , the risk of developing chronic ( > 200 sick days ) pain was 8 times lower for the Early Activation group . This investigation shows that relatively simple changes in treatment result in reduced sickness absenteeism for ‘ first‐time ’ sufferers only . Consequently , the content and timing of treatment for pain appear to be crucial . Properly administered early intervention may therefore decrease sick leave and prevent chronic problems , thus saving considerable re sources The main aim of this study was to assess the effects of a fitness assessment and exercise consultation on physical activity over 1 year in non-regularly active participants drawn from a socially and economically deprived community . Of 3000 people invited to volunteer for either intervention , 225 fitness assessment volunteers  were r and omly assigned to an experimental or control group ; 145 exercise consultation volunteers  were similarly assigned . Physical activity was measured at baseline , 4 weeks , 3 months ( plus an intervention re-test ) , 6 months and 1 year . Analysis of variance and follow-up Bonferroni analysis showed that , for those not regularly active at baseline , physical activity increased significantly to 4 weeks , was maintained to 6 months but had fallen by 1 year . Only those receiving an exercise consultation significantly increased their physical activity after 1 year . Compared with fitness assessment s , chi-square analysis showed that significantly more non-regularly active participants volunteered for an exercise consultation and those receiving an exercise consultation had significantly better long-term study adherence than those receiving a fitness assessment . The study also showed that , contrary to popular opinion , those in a socially and economically deprived community are not ' hard to reach ' and respond well to physical activity interventions Study Design . Sixteen-week intervention for chronic patients with low back pain ( LBP ) with 9-month follow-up . Primary r and omization at 4 weeks into either supervised Swiss ball exercise or an exercise advice group . Objective . To evaluate changes in disability and pain in individuals with chronic LBP after combined treatment and exercise interventions  , and to evaluate whether changes in self-report or physical measures would best explain improvements in disability Summary of Background Data . There is a need to underst and what the effectiveness of a clinical ly applicable treatment intervention is for an individual ’s perception of their back pain . There is insufficient evidence about the different combinations of manual treatment that commonly precede involvement in exercise programs . Methods . Sixty individuals with chronic nonspecific LBP ( at least 3-month duration ) were r and omly assigned ( after 4 weeks of manipulative or nonmanipulative treatment ) to either a supervised Swiss ball exercise group , or an advice group . The exercise intervention was for 12 weeks with a long-term follow-up of 9 months . Self-report measures and physical measures ( endurance times and myoelectric fatigue ) were collected throughout the study . Results . Self-rated disability improved more after the treatment period for individuals who received supervised exercise compared with advice alone . There was no difference found between individuals who received manipulative or nonmanipulative treatment . Multiple regression analysis found that self-report measures best explained improvements in disability throughout the study . Long-term findings showed no group differences . Conclusion . Supervised exercise is a more successful subsequent to manual treatment compared with exercise advice . The improvements associated with this type of program were primarily manifested in the psychologic self-report measures rather than physical measurements Context  Neck pain is common among primary care patients . Evidence on the effectiveness of therapies for neck pain is limited . A previous r and omized , controlled trial suggested benefits from manual therapy and physical therapy . Contribution This r and omized , controlled trial of manual therapy , physical therapy , and continued care by a doctor confirms the superiority of manual therapy and physical therapy over continued care . At 7 weeks , 68.3 % of patients in the manual therapy group reported resolved or much improved pain , compared with 50.8 % of patients in the physical therapy group and 35.9 % of patients in the continued care group . Clinical Implication s Primary care physicians should consider manual therapy when treating patients with neck pain .  The Editors Neck pain is a common problem in the general population , with point prevalences between 10 % and 15 % ( 1 - 3 ) . It is most common at approximately 50 years of age and is more common in women than in men ( 1 , 2 , 4 - 6 ) . Neck pain can be severely disabling and costly , and little is known about its clinical course ( 7 - 9 ) . Limited range of motion and a subjective feeling of stiffness may accompany neck pain , which is often precipitated or aggravated by neck movements or sustained neck postures . Headache , brachialgia , dizziness , and other signs and symptoms may also be present in combination with neck pain ( 10 , 11 ) . Although history taking and diagnostic examination can suggest a potential cause , in most cases the pathologic basis for neck pain is unclear and the pain is labeled nonspecific . Conservative treatment methods that are frequently used in general practice include analgesics , rest , or referral to a physical therapist or manual therapist ( 12 , 13 ) . Physical therapy may include passive treatment , such as massage , interferential current , or heat applications , and active treatment , such as exercise therapies . Physical therapists can specialize in passive manual ( or h and s-on ) techniques , including mobilization or manipulation ( high-velocity thrust techniques ) , also referred to as manual therapy ( 14 - 19 ) . According to the International Federation of Orthopedic Manipulative Therapies , Orthopedic manipulative ( manual ) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities ( unpublished data ) . Today , many different manual therapy approaches are applied by various health professionals , including medical doctors , physical therapists , massage therapists , manual therapists , chiropractors , and osteopathic doctors . Review s of trials involving manual therapy or physical therapy show that most interventions in these categories are characterized by a combination of passive and active components ( 20 - 23 ) . Although a combination of manual therapy or physical therapy that includes exercises appears to be effective for neck pain , these therapies have not been studied in sufficient detail to draw firm conclusions , and the method ologic quality of most trials on neck pain is rather low ( 20 - 23 ) . Koes and colleagues ( 24 , 25 ) performed a r and omized trial on back and neck pain and found promising results for manual therapy and physical therapy in subgroup analyses of patients with neck pain . In our r and omized , controlled trial , we compared the effectiveness of manual therapy , physical therapy , and continued care by a general practitioner in patients with nonspecific neck pain . Methods Patients Patients with nonspecific neck pain whose clinical presentation did not warrant referral for further diagnostic screening were referred to one of four research centers by 42 general practitioners for study selection . We excluded patients whose history , signs , and symptoms suggested a potential nonbenign cause ( including previous surgery of the neck ) or evidence of a specific pathologic condition , such as malignancy , neurologic disease , fracture , herniated disc , or systemic rheumatic disease . Two research assistants who were experienced physical therapists and were blinded to treatment allocation performed physical examinations at baseline and follow-up . They used st and ardized inclusion and exclusion criteria and performed a short neurologic examination ( Appendix Table 1 ) and range-of-motion assessment . The eligibility criteria were age between 18 and 70 years , pain or stiffness in the neck for at least 2 weeks , neck symptoms reproducible during physical examination , willingness to adhere to treatment and measurement regimens , no physical therapy or manual therapy for neck pain during the previous 6 months , no involvement in litigation , and written informed consent . Patients with concurrent headaches , nonradicular pain in the upper extremities , and low back pain were not excluded , but neck pain had to be the main symptom for all patients . R and om Assignment and Data Collection All patient data were collected before r and omization . Patients were assigned to a treatment group on the basis of block r and omization after prestratification for symptom severity ( severity scores < 7 points or 7 points on a scale of 0 to 10 ) ; age ( < 40 years or 40 years ) ; and , mainly for practical reasons , research center ( four local centers ) . R and omized permuted blocks of six patients were generated for each stratum by using a computer-generated r and om-sequence table . A research er who was not involved in the project prepared opaque , sequentially numbered sealed envelopes that contained folded cards indicating one of the three interventions . Interventions The intervention period lasted 6 weeks . Patients were allowed to perform exercises at home and to continue medication prescribed at baseline or use over-the-counter analgesics . Other co- interventions were discouraged but were registered if they occurred . Within the boundaries of the protocol , treatment could be reassessed and adapted to the patient 's condition . The specific treatment characteristics were registered at each visit . A maximum number of visits was set for each intervention group ; however , the patients did not have to complete this maximum number if symptoms had resolved . Manual Therapy Our approach to manual therapy was eclectic and incorporated several techniques used in western Europe , North America , and Australia , including those described by Cyriax , Kaltenborn , Maitl and , and Mennel ( 15 , 16 , 19 ) . In our trial , manual therapy ( defined as the use of passive movements to help restore normal spinal function ) included h and s-on muscular mobilization techniques ( aim ed at improving soft tissue function ) , specific articular mobilization techniques ( to improve overall joint function and decrease any restrictions in movement at single or multiple segmental levels in the cervical spine ) , and coordination or stabilization techniques ( to improve postural control , coordination , and movement patterns by using the stabilizing cervical musculature ) ( 26 ) . Joint mobilization is a form of manual therapy that involves low-velocity passive movements within or at the limit of joint range of motion ( 27 ) . Manual therapists must undergo extensive training to be able to skillfully perform mobilization techniques ( 15 , 19 ) . Spinal manipulations ( low-amplitude , high-velocity thrust techniques ) were not included in this protocol . Forty-five minute treatment sessions were scheduled once per week , for a maximum of six treatments . Six experienced manual therapists acknowledged by the Netherl and s Manual Therapy Association performed the treatment . Physical Therapy The physical therapists used a combination of several treatment options , but active exercise therapies were the cornerstone of their strategy . Active exercise therapy involves participation by the patient and includes active exercises ( to improve strength or range of motion ) ,  postural exercises , stretching , relaxation exercises  , and functional exercises . Manual traction or stretching , massage , or physical therapy methods , such as interferential current or heat applications , could precede the exercise therapy . Specific manual mobilization techniques were not included in this protocol . Thirty-minute treatment sessions were scheduled twice per week for a maximum of 12 treatments . The treatment was performed by five experienced physical therapists . We prevented cross-contamination with manual therapy by choosing physical therapists who were not manual therapy specialists . Continued Care by a General Practitioner Each patient in this group received st and ardized care from his or her general practitioner , including advice on prognosis , advice on psychosocial issues , advice on self-care ( heat application , home exercises ) , advice on ergonomics ( for example , size of pillow , work position ) , and encouragement to await further recovery . The treatment protocol was similar to the practice guidelines for low back pain issued by the Dutch College of General Practitioners ( 28 ) . Patients received an educational booklet containing ergonomic advice and exercises ( 29 ) . Medication , including paracetamol or nonsteroidal anti-inflammatory drugs , was prescribed on a time-contingent basis if necessary . Ten-minute follow-up visits , scheduled every 2 weeks , were optional , and referral during the intervention period was discouraged . Outcome Measures Data were collected at the research center after 3 and 7 weeks . At 7 weeks , treatment results were expected to be maximal . The patients were repeatedly asked not to reveal any information about their treatment allocation to the research assistants . The success of blinding was evaluated at 7 weeks . Primary outcome measures focused on perceived recovery , pain , and functional disability . Patients rated perceived recovery on a 6-point ordinal transition scale , ranging from much worse to completely recovered . Success was defined a priori as completely recovered or much improved ( 30 ) . In addition , on the basis of the systematic assessment of spinal mobility , palpation , and pain reported by Background Osteoarthritis of the knee involving predominantly the medial tibiofemoral compartment is common in older people , giving rise to pain and loss of function . Many people experience progressive worsening of the disease over time , particularly those with varus malalignment and increased medial knee joint load . Therefore , interventions that can reduce excessive medial knee loading may be beneficial in reducing the risk of structural progression . Traditional quadriceps strengthening can improve pain and function in people with knee osteoarthritis but does not appear to reduce medial knee load . A neuromuscular exercise program , emphasising optimal alignment of the trunk and lower limb joints relative to one another , as well as quality of movement performance , while dynamically and functionally strengthening the lower limb muscles , may be able to reduce medial knee load . Such a program may also be superior to traditional quadriceps strengthening with respect to improved pain and physical function because of the functional and dynamic nature . This r and omised controlled trial will investigate the effect of a neuromuscular exercise program on medial knee joint loading , pain and function in individuals with medial knee joint osteoarthritis . We hypothesise that the neuromuscular program will reduce medial knee load as well as pain and functional limitations to a greater extent than a traditional quadriceps strengthening program . Methods / Design 100 people with medial knee pain , radiographic medial compartment osteoarthritis and varus malalignment will be recruited and r and omly allocated to one of two 12-week exercise programs : quadriceps strengthening or neuromuscular exercise . Each program will involve 14 supervised exercise sessions with a physiotherapist plus four unsupervised sessions per week at home . The primary outcomes are medial knee load during walking ( the peak external knee adduction moment from 3D gait analysis ) , pain , and self-reported physical function measured at baseline and immediately following the program . Secondary outcomes include the external knee adduction moment angular impulse , electromyographic muscle activation patterns , knee and hip muscle strength , balance , functional ability , and quality -of-life . Discussion The findings will help determine whether neuromuscular exercise is superior to traditional quadriceps strengthening regarding effects on knee load , pain and physical function in people with medial knee osteoarthritis and varus malalignment . Trial Registration Australian New Zeal and Clinical Trials Registry reference : Background The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions . Methods The conclusions are based on the results of systematic review s of r and omized clinical trials ( RCTs ) , widely accepted and primarily UK and United States evidence -based clinical guidelines , plus the results of all RCTs not yet included in the first three categories . The strength/ quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs . Results By September 2009 , 26 categories of conditions were located containing RCT evidence for the use of manual therapy :  13 musculoskeletal conditions , four types of chronic headache and nine non-musculoskeletal conditions . We identified 49 recent relevant systematic review s and 16 evidence -based clinical guidelines plus an additional 46 RCTs not yet included in systematic review s and guidelines .Additionally , brief references are made to other effective non-pharmacological , non-invasive physical treatments . Conclusions Spinal manipulation/mobilization is effective in adults for : acute , subacute , and chronic low back pain ; migraine and cervicogenic headache ; cervicogenic dizziness ;  manipulation/mobilization is effective for several extremity joint conditions ; and thoracic manipulation/mobilization is effective for acute/subacute neck pain . The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration , and for manipulation/mobilization for mid back pain , sciatica , tension-type headache , coccydynia , temporom and ibular joint disorders , fibromyalgia , premenstrual syndrome , and pneumonia in older adults . Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation , or for Stage 1 hypertension when added to an antihypertensive diet . In children , the evidence is inconclusive regarding the effectiveness for otitis media and enuresis , and it is not effective for infantile colic and asthma when compared to sham manipulation . Massage is effective in adults for  chronic low back pain and chronic neck pain . The evidence is inconclusive for knee osteoarthritis , fibromyalgia , myofascial pain syndrome , migraine headache , and premenstrual syndrome . In children , the evidence is inconclusive for asthma and infantile colic Background It is well recognised that the adoption and longer term adherence to physical activity by adults to reduce the risk of chronic disease is a challenge . Interventions , such as group and home based physical activity programs , have been widely reported upon . However few studies have directly compared these interventions over the longer term to determine their adherence and effectiveness . Participant preference for home based or group interventions is important . Some evidence suggests that home based physical activity programs are preferred by middle aged adults and provide better long term physical activity adherence . Physiotherapists may also be useful in increasing physical activity adherence , with limited research on their impact . Methods ' Physical Activity at Home ' is a 2 year pragmatic r and omised control trial , with a non-r and omised comparison to group exercise .  Middle-aged adults not interested in , or unable to attend , a group exercise program  will be targeted . Sedentary community dwelling 50 - 65 year olds with no serious medical conditions or functional impairments will be recruited via two mail outs using the Australian federal electoral roll . The first mail out will invite participants to a 6 month community group exercise program . The second mail out will be sent to those not interested in the  group exercise program inviting them to take part in a home based intervention .  Eligible home based participants will be r and omised into a 6 month physiotherapy-led home based physical activity program or usual care . Outcome measures will be taken at baseline , 6 , 12 , 18 and 24 months . The primary outcome is physical activity adherence via exercise diaries . Secondary outcomes include the Active Australia Survey , accelerometry , aerobic capacity ( step test ) , quality of life ( SF-12v2 ) , blood pressure , waist circumference , waist-to-hip ratio and body mass index . Costs will be recorded prospect ively and qualitative data will be collected . Discussion The planned 18 month follow-up post intervention will provide an indication of the effectiveness of the group and home based interventions in terms of adherence to physical activity , health benefits and cost . If the physiotherapy-led home based physical activity program is successful it could provide an alternative option for physical activity program delivery across a number of setting s . Trial registration Australia and New Zeal and Clinical Trials Register ( ANZCTR ) : Background : Long-term musculoskeletal pain is a common problem in primary health care setting s that is difficult to treat . Two common treatments are mental relaxation and massage . Scientific studies show contradictory results . Furthermore , many studies lack long-term follow-up even though it is a chronic disorder . The purpose of this r and omized clinical trial was to assess possible effects of massage as compared to listening to relaxation tapes in conditions of ‘ diffuse ’ and long-term musculoskeletal pain . Methods : 129 patients from primary health care suffering from long-term musculoskeletal pain were r and omized to either a massage or mental relaxation group , and assessed before , during and after treatment . Results : During treatment there was a significant improvement in the three main outcome measures : self-rated health , mental energy , and muscle pain only in the massage group as compared to the relaxation group . However , at the 3-month post-treatment follow-up , there was a significant worsening in the outcome measures ( time × group effect p < 0.05 ) back to initial rating levels in the massage group as compared to no changes in the relaxation group . Conclusion : Massage , but not mental relaxation , is beneficial in attenuating diffuse musculoskeletal symptoms . Beneficial effects were registered only during treatment . This lack of long-term benefits could be due to the short treatment period or treatments such as these do not address the underlying causes of pain . Future studies of long-term pain should include longer treatment periods and post-treatment follow-up . It might also be worthwhile assessing the long-term benefits from booster treatment after the initial intense treatment period Background Non-specific chronic low back pain ( NSCLBP ) has become a significant problem due to high healthcare utilization , rising costs of care and perceived limitations of effectiveness of many current treatments . Systematic review s have repeatedly concluded that , on average across participants , exercise for NSCLBP appears effective in decreasing pain and improving function . Not all people with NSCLBP benefit from exercise programs and it would assist care-providers and care-seekers if factors that impact on program effectiveness and success were identified . Methods and design The study will be a r and omised controlled trial comparing an exercise rehabilitation program informed by a participant preferences question naire compared to a program without this guideline for patients with chronic low back pain . A sample of 150 patients will be recruited in Melbourne , Australia through community-based healthcare clinics that provide supervised exercise rehabilitation programs for people with non-specific chronic low back pain . Clinicians will be r and omly assigned to exercise preferences question naire or no question naire and participants will be allocated in a concealed manner . A qualitative focus group study of exercise instructor feedback about the exercise preferences instrument will be embedded in the research design . Two qualitative focus group studies will also be conducted for participants in the intervention and the control groups to obtain feedback about participants ' experiences of the two types of exercise programs . The primary outcomes will be functional ability , pain , fear avoidance , exercise adherence . Discussion This trial will evaluate the effectiveness of individualised exercise prescription compared to usual exercise prescription for NSCLP and , using feedback following the trial , refine the exercise preferences question naire
Interventions such as supervised or individualised exercise therapy and self-management techniques may enhance exercise adherence .
BACKGROUND Chronic musculoskeletal pain ( CMP ) is a major health problem , accounting for approximately one-quarter of general practice ( GP ) consultations in the United Kingdom ( UK ) .
Exercise and physical activity is beneficial for the most common types of CMP , such as back and knee pain .
However , poor adherence to exercise and physical activity may limit long-term effectiveness .
OBJECTIVES To assess the effects of interventions to improve adherence to exercise and physical activity for people with chronic musculoskeletal pain .