Feb. 4, 2009 Exercise is commonly used to improve physical function, decrease symptoms and minimize disability caused by chronic low back or neck pain. Numerous randomized trials and clinical practice guidelines have supported this practice, and studies suggest that individually tailored, supervised exercise programs are associated with the best outcomes.
Nevertheless, there is a lack of knowledge about exercise prescription, including who is prescribing it, who is getting it and what type of exercise is being prescribed. A new study, funded by the National Institutes of Health, examined these questions and found that exercise may be underutilized for chronic back and neck pain.
Led by Timothy S. Carey and Janet K. Freburger of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, researchers conducted a telephone survey of almost 700 individuals with chronic back or neck pain who saw a physician, chiropractor and/or physical therapist (PT) during the previous 12 months. They asked participants whether they were prescribed exercise, the amount of supervision received, and the type, duration and frequency of the prescribed exercise.
"Less than 50 percent of the subjects in our sample were prescribed exercise, one of the few moderately effective therapies for the highly disabling illness of chronic back and neck pain," the authors state. The type of provider seen played a major role in whether participants received a prescription. Of those who received exercise prescription, 46 percent received the prescription from a PT, 27 percent from a physician, and 21 percent from a chiropractor. The authors note that these findings agree with previous studies that have found that "who you see is what you get."
Although most of the 700 participants had seen a physician, only 14 percent were prescribed exercise. Some of those who were not prescribed exercise by a physician, however, were likely referred to a PT who did prescribe exercise. Not surprisingly, Pts were the most likely to prescribe exercise, although about a third of those who saw a PT did not receive an exercise prescription.
For those who were prescribed exercise, the type of provider seen determined the amount of supervision and, to some extent, the types of exercises prescribed. Pts were more likely to provide supervision and prescribe stretching and strengthening exercises, practices which follow current guidelines and lead to better outcomes.
"Considering current evidence on the efficacy of exercise, these findings demonstrate that exercise is being underutilized as a treatment for chronic back and neck pain," the authors state. They note that none of the hypothesized health-related characteristics, such as pain or weakness in the extremities, hypothesized whether an individual was prescribed exercise and that providers' decisions to prescribe exercise did not appear to be influenced by the degree of impairment. However, women, people with a higher education level and those receiving worker's compensation were more likely to be prescribed exercise. This may be because women and more educated individuals are more likely to be active participants in their care and those with worker's compensation are frequently injured on the job and treated with the goal of returning to work.
"Although exercise prescription provided by Pts appears to be the most in line with current guidelines, there is much room for improvement by all types of providers who prescribe exercise for patients with chronic back and neck pain," the authors note. They suggest that future studies should explore barriers to prescription of exercise treatments, such as practitioner knowledge, organizational aspects of the practice, and poor reimbursement for exercise instruction compared with other types of treatment.
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- Freburger et al. Exercise prescription for chronic back or neck pain: Who prescribes it? who gets it? What is prescribed? Arthritis & Rheumatism, 2009; 61 (2): 192 DOI: 10.1002/art.24234
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