A walking-based program to address the physical, mental and social aspects of low back pain: A single-case study

by | Feb 1, 2023 | Environmental Physiotherapy, Students in EPT, Urban Design and Sustainable Communities | 0 comments

Last sprint in this Bachelor of Physiotherapy. Our bachelor thesis needs to be innovative! Looking for a partnership with a technology company to use micro sensors to assess the gait quality of patients. A professor comes with another great idea: prove that a smartphone camera can be almost as efficient if not more efficient than those sensors to assess gait? Opening possibilities…! Questioning the very definition of innovation. Do we have to invent something new since innovation is about the diffusion of an invention.

What a beautiful activity that humans have invented and already mastered throughout evolution: walking. Yet we are walking less and less. So how can we re-diffuse (innovate) walking in our urban societies?

According to the WEF (1), the WHO (2), the UN (3) and urban analysis, our societies will face several challenges in the 21st century. Four of those major challenges relevant to healthcare are physical, psychological, social, and environmental (1-6):

  • Physical: because inactivity, obesity, aging, chronic disease are increasing.
  • Psychological and social: because we are spending more time indoors with human-technology interactions and fewer real human-human or human-nature interactions.
  • Environmental: because our societies must decrease production & consumption and adapt to environmental changes.

Can a simple activity like walking address those 4 challenges in our physiotherapy practice and contribute to the treatment of the most common musculoskeletal issue: low back pain? (7-12).

Walking is accessible to almost everyone. Walking gently mobilizes the spine, activates muscles, affects endogenous pain modulation (13-17), and increases cardiovascular health. Physical activity has been shown to increase mental energy levels, and even more so when performed outdoors (18-22). Urban research has shown that more walkable areas improve social life and therefore quality of life. Walking needs almost no equipment, which makes it more eco-friendly than most other physical activities.

Kyan Rytzell (BSc)

Kyan Rytzell (BSc)

Physiotherapist and Correspondent at Pedestrian Space

Kyan Rytzell is a global citizen, born in Geneva. He studied Physiotherapy, in Spain and Netherlands. His curiosity led him to work in France, the Netherlands, the USA, and Norway, to work in renowned restaurants, teach living anatomy, take part in Military Ski Patrols or win running races, renovate a 200-year-old farm, free-willingly be homeless while attending university, or lead urbanism projects.
Kyan is convinced that our well-being stems from the quality of our relationships, the environment around us, and the courageous decision to create ourselves.

I observed that when an LBP patient learns that walking is more beneficial to his/her health than passive treatment, then a huge mindset shift happens in several aspects of their Life (23-24). My thesis used walking as an approach to optimize the behavior of the patient towards a more active, outdoor, and social lifestyle.

The intervention was a 5-week walking-based program, which consisted of short walks of 10 minutes, 3 times per week. Meaningful walks are considered as walks with an associated goal to it. The program was coupled with exercise therapy, patient education aiming a conceptual change in perceptions related to the interaction with the urban environment, biopsychosocial aspects of low back pain, and improving adequate coping strategies. Perceived level of disability was measured with the Oswestry Disability Index, pain using the VAS, and quality of life using the SF-12. Additionally, two semi-structured interviews were performed to assess program feasibility. 

At the end of the program, pain decreased from 87mm to 46mm which exceed the minimal detectable change (MDC) of 30mm. The Oswestry Disability Index (14% to 6%, MDC of 15.35%) and SF-12 (PCS (physical): 52.43 to 52.20, MCS (mental): 54.85 to 50.75). The qualitative interviews outlined that the patient experienced some improvements in quality of Life, such as improved sleep quality, work and less headaches. The patient now engages in more outdoor and social activities, became better at self-managing pain behaviors, and feels more confident in controlling a LBP relapse. Also according to the interviews, the patient adherence to the program was linked to the direct interaction to the urban environment, the social anchor*, perceived simplicity, and the rational behind the intervention. The interview outlined that targeting the populations at risk, as well as socio-economic factors are of crucial importance for the successful implementation of this approach.

Photo by Matthew Wheeler on Unsplash

One challenge was that the patient came with expectations of what a physiotherapy (usually passive treatment) session is about, when suddenly the therapist promoted “walking” and social activities as a possible treatment. In my international experience, those expectations of physiotherapy greatly differ from country to country, which highlights the need to “diffuse” a more active, environmentally friendly approach in regions where physiotherapy is more associated with passive treatments.

Another challenge was to make the walking or physical activity interesting and meaningful. Possibilities to use the patient’s environment to increase physical activity were discussed. For example, we noticed that going one stair after another created pain yet climbing them two by two did not provoke the symptoms, therefore the latter was performed instead of using the elevator. Other strategies to make the physical activity more meaningful included going for a walk and having a chat while ordering a coffee, going for a walk in a park famous for its statues or finding your favorite tree, going for a walk, and send a message to someone you have not talked in a long time.

Goal setting was an important part of the process. As the patient progressed, a session was dedicated to find a suitable activity to move towards. Goal setting and reaching sub-goals are known to create a release of dopamine and enhance a sense of progress (25-27). Making for two great examples of social anchors: The patient decided to take part in a popular cross-country race and decided to train with a friend. He also used this opportunity to visit his parents on the way back from skiing.

 

Photo by Stephen Fang on Unsplash

So what to make of my study with a view to future physiotherapy practice?

For successful implementation, education about physical activity is as important as finding solutions tailored to the patient’s direct urban environment. It is crucial to make physical activity as simple and meaningful as possible for the patient. Nature-based solutions can increase the attractiveness of walking and are beneficial for mental energy as well. The goal is a mindset shift toward more active, outdoor, and socially engaged health behaviours. A “social anchor” is an interesting concept and tool, as it makes the patient proactive towards sustained healthy behaviours and creates a safety net to maintain those activities. The question this raises for me is: How can we promote meaningful activities to create resilient communities?

 

*Social anchor is a term used to describe a process of involving the patient in a physical activity, which is then diffused into their social circle. A social anchor is considered a confirmed behavioural change because the activity has been done with a peer, which increases the engagement and self-efficacy of the patient. (28-31)

References

Header image by Tamara Menzi on Unsplash

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