Veterans Back Pain Exercise and Therapy

PICOT Question
Introduction
Low back pain is a common health challenge for both active and former military service members. Among the military veterans, low back pain places higher risk and has been indicated to be bear the potential for long-term disability (Bagg et al., 2017). There is a lack of effective treatment strategies, and thus, military veterans rely on pain management strategies and other medical strategies, e.g., medical imaging, opioids, injections, and surgery. To both the Department of Defense (DoD) and the Department of Veteran Affairs (VA), the costs of care for members with low back pain have been on the rise; necessitating the need for research on the effectiveness of some of the available methods for treating and managing low back pain. Some of the methods available are non-narcotic pain medication, yoga stretches, and physiotherapy. These interventions can be administered in combination or singly (Bagg et al., 2017). This study assesses the effectiveness of non-narcotic pain medications combined with yoga and cold/heat therapy. Moreover, it compares the above with the use of non-narcotic pain medications to lower back pain (using the DVPRS pain scale) among veterans diagnosed with low back pain for three months.
Background and literature review
The management or treatment of low back pain, whether acute, sub-acute, or chronic, has from practice, shown to have less than desired outcomes. As a result, most veterans with low back pain have resulted in one or several unconventional methods for management of the same. Some of these alternative strategies include non-narcotic medications, yoga stretches, and hot/cold therapy. Non-narcotic analgesics are an effective strategy in dealing with mild to moderate low back pain. Some non-narcotic analgesics are aspirin, Tylenol, and NSAIDs, e.g., fenoprofen, sulindac, carprofen, and ketoprofen (Qaseem et al., 2017).
Yoga stretches have also been shown to offer effectiveness intervention for persons exercising low back pain. However, the findings regarding yoga are mixed, and those that report effectiveness have some significant limitations. That notwithstanding, yoga stretches have been reported to help deal with disability caused by low back pain, depression for low back pain patients, and as compared to a control group, the level of pain was significantly lower for those practicing yoga stretches (Groessl et al., 2008; Williams et al., 2009).
Heat/cold therapy has also been shown by research findings to offer effective remedies for both acute and moderate low back pain (Dehghan & FarahbOD, 2014). Even though the two might not have the same results on the same patient, they have been shown to work depending on the situation. For example, hot therapy works, especially if the cause of low back pain is the poor contraction of the otherwise smooth muscles, and cold therapy might work in the short-term by numbing nerve endings.
Purpose of the study
Even though research on the effectiveness of individual intervention for low back pain is wide and intensive, there is limited research on a combination of these interventions. In practice, persons suffering from low back pain will use several of these strategies to alleviate the pain. This study, therefore, compares how a combination of these strategies, namely, non-narcotic medication with yoga and therapy and how its effectiveness compares with non-narcotic medications used singly.
Literature search and strategies
A systematic literature review method was adopted or this study. Given the purpose of the study, this method is the most appropriate as it allows for a review of previous research to determine the findings and how they reflect on the current research problem.
The search was done in five electronic databases; Medline, CINAHL, Cochrane Library, PsycLIT, and EBSCOhost. The search was done using the keywords; “Low back pain,” “multifaceted treatment,” “treatment effectiveness,” “Yoga,” “Non-narcotic,” and “physiotherapy.”
The search was done by the principal research, and results were first analyzed on topic and abstract to determine whether they meet the inclusion criteria. Once determined to fit, they were further examined in the body text to determine whether they meet the specifics of the PICOT question.
The inclusion criteria: meet the PICOT question, reported on any of the low back pain treatment strategies, studies that published in English, not later than 2000, and they were research paper with a sample included. Exclusion criteria: unpublished studies include participants under the age of 18 include commentaries or opinions, and studies published in a non-English language.
The search strategy generated 247 results, of which 147 were considered to be potentially relevant to the study subject. There were three unpublished articles, and none that includes underage participants or published in non-English languages.
After review of the abstract, 39 studies where identified, and after further review of the text, 27 were expunged for not addressing low back pain. Figure 1, represents the eligibility assessment and inclusion.
Figure 1. Representation of the assessment and inclusion process
First author, year
Title
Study objective
Study design
Intervention
Participants
Results
Conclusion
Guzmán, J.
2001

Multidisciplinary rehabilitation for chronic low back pain: a systematic review
To assess the effectiveness of multidisciplinary biopsychosocial rehabilitation on patients with chronic LBP
Systematic literature review
N/A
N/A
12 randomized comparisons showed intensive; multidisciplinary biopsychosocial rehabilitation improves function as compared to inpatient non-multidisciplinary treatments
Intensive, multidisciplinary biopsychosocial rehabilitation with functional restoration reduces and improves the function of persons with low back pain

Nitsure, P.V.
2014
Comparison of Elastic Resistance Band Exercises and Yoga in Physiotherapy Students with Chronic Non-Specific Low Back Pain: A Randomized Clinical Trial
To study and compare the effectiveness of elastic resistance band exercises and yoga in physiotherapy for chronic non-specific LBP
Randomized clinical trial
Group A – elastic band exercises Group B – yoga for ten days
40 Physiotherapy students with chronic non-specific LBP
Elastic resistance band exercises had higher improvement in pain reduction, strength, flexibility, and functional disability than yoga
Ten sessions of elastic resistance band exercises showed to have better results than yoga in reducing low back pain

Hayden, J.A.
2005
Systematic Review: Strategies for Using Exercise Therapy to Improve Outcomes in Chronic Low Back Pain
To determine specific exercises that decrease pain and improve function for LBP
Systematic literature review
N/A
N/A
Improve pain scores were found in individually designed programs, supervised home exercises, group, and individually supervised exercises as compared to home exercises only.
Exercise therapy composes individually designed program, stretching or strengthening and delivered in a supervised environment may improve pain and function for chronic LBP

Stahl, J.
2017
Prochlorperazine/Diphenhydramine vs. Ketorolac for Treatment of Acute-on-Chronic Back Pain Exacerbations in the Emergency Department
Investigate whether treatment with prochlorperazine and diphenhydramine can provide pain relief for chronic low back pain
Randomized clinical trial
One group - prochlorperazine 10 mg plus diphenhydramine 50 mg intravenously (IV)
Other group - standard of care treatment with ketorolac 30 mg IV.
6 Patients with a chief complaint as low back pain
Patients in one group experienced pain relief after 30 minutes ad compared to the baseline as 60 minutes.
There is potential for the use of prochlorperazine and diphenhydramine as a treatment for chronic low back pain

Patel, H. D.
2019

Efficacy and Safety of Combination of NSAIDs and Muscle Relaxants in the Management of Acute Low Back Pain
Investigation on the combined effect of muscle relaxants and pain killers for low back pain
Open-label, prospective, multicenter study
One tablet or the fixed-dose of combined chlorzoxazone 500mg and ibuprofen 400mg or ibuprofen 400mg thrice daily for seven days
406 Patients with acute low back pain
Primary outcomes showed improvement in pain at 3 and 7 days after treatment
Fixed-dose combination of chlorzoxazone and ibuprofen sows superior efficacy with low back pain than monotherapy of ibuprofen

Qaseem, A.
2017
Noninvasive Treatments for Acute, Sub-acute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.
To provide treatment guidelines for medical providers based on efficacy and safety for those experiencing acute, sub-acute, and chronic back pain.
Systematic review
N/A
N/A
Moderate quality evidence showed that a heat wrap moderately improved pain relief (at five days) and disability (at four days) compared with a placebo

Low-quality evidence demonstrated that a combination of heat and exercise decreased pain and improved RDQ scores in seven days in comparison to exercise alone. Patients with acute pain. evidence

Low-quality evidence showed that Iyengar yoga resulted in moderately lower pain scores and improved function compared to usual care at 24 weeks.
For patients with chronic low back pain, clinicians and patients should initially select a non-pharmacologic treatment with exercise, multidisciplinary rehab, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy or spinal manipulation (low-quality evidence).

Williams, K.
2009
Evaluation of the Effectiveness and Efficacy of Iyengar Yoga Therapy on Chronic Low Back Pain.
To obtain enough data to update the literature on the effectiveness of low-level laser therapy on chronic back pain.
RCT
Yoga sessions lasted 90 minutes, and 30 minutes of yoga at home
Individuals with chronic low back pain
Improvements were observed for all outcomes in the group practicing yoga and reduced usage of pain medication.
Yoga enhances functional disability, pain intensity, as well as, depression in adults with chronic low back pain.

Dehghan, M.
2014
The efficacy of thermotherapy and cryotherapy on pain relief in patients with acute low back pain, a clinical trial study. 
To examine the efficacy of thermotherapy and cryotherapy, alongside a routine pharmacologic treatment on pain relief
RCT
Group A was given cryotherapy, group B thermotherapy, and group C naproxen.
Patients experiencing acute back pain
Thermotherapy patients showed significantly less pain compared to cryotherapy and control.
Application of thermo-therapy and cryotherapy accompanied naproxen, relieving acute back pain.
Taylor, S. L.
2019
Complementary and integrated health approaches: What do Veterans use and want.
To conduct a large national survey of veterans’ interest in, frequency of and reasons for the use of, and satisfaction with, 26 complementary and Integrative Health (CIH) approaches.
Exploratory design
Use of complementary and integrative health (CIH)
1,230 veterans using CIH
Veterans report relatively high past year use of CIH approaches and many more report interest in CIH.
The prevalence of CIH utilization by veterans appears to be much higher than that reported in the general population.
Chou, R.
2017
Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline.
To review systematically current evidence on non- pharmacological therapies for acute or chronic non-radicular or radicular low back pain
Systematic review
N/A
N/A
Evidence indicates that tai chi and mindfulness-based stress reduction are effective for chronic low back pain.
Nonpharmacologic therapies are effective for short-term effects on low back pain.

Denneson, L. M.
2011
Complementary and alternative medicine use among veterans with chronic noncancer pain
To investigate the use and willingness to use complementary alternative medicine (CAM) among veterans.
Retrospective study design
CAM users and nonusers
401 Veteran with chronic noncancerous pain
Almost all veterans were willing to use CAM, even though the difference between users and nonusers where insignificant
CAM may have a wider appeal among veterans with chronic back pain

Kim, E. J.
2015
Effect of heating and cooling combination therapy on patients with chronic low back pain: study protocol for a randomized controlled trial.
To determine the efficacy and safety of heat/cold therapy in treating chronic back pain
Random controlled trial
Therapy entailed being given ten 15-minute treatments over four weeks. The protocol entailed five cycles of heating/ cooling therapy.
80 Patients who have chronic back pain
The beneficial effects of heating and cooling therapy may be mediated by changing blood flow, decreasing inflammation, induction of contraction and relaxation of blood vessels, decreasing edema, or decreasing muscle stiffness, but the underlying mechanism remains unproven.
These findings are crucial in filling the knowledge gap on the effectiveness of the combination of non-narcotic medication, yoga, and therapy as compared to non-narcotic medications used singly. From the assessment presented in this paper, it is clear that there is limited research on the combination of the various pain management intervention used for patients experiencing low back pain. This notwithstanding, there is a significant research effort into the various intervention (Chou, 2017; Denneson, 2011; Kim, 2015; Taylor, 2019). However, some of the studies covered in this review have made an effort to study the effect of the combined intervention, and these will come in handy (Guzmán, 2001; Hayden, 2005; Patel, 2019; Stahl, 2017; Taylor, 2019).
Critique
First, this current study suffers the familiar limitation of all literature review studies. Also, the studied contained here as the sources of the data are diverse, and each source suffers specific limitations. For example, Guzmán et al. (2001), Hayden et al. (2005), Qaseem et al. (2017), and Chou et al. (2017) are all systematic review methods that do not present any solid field-level data. This is a major limitation as such sources are not founded on primary field-level data. In other studies, the size of the sample included in the study is simply too small to qualify for transferability. For example, Nitsure et al. (2014) and Stahl et al. (2017) both are randomized controlled trials – a scientifically relevant research method – however, the research sample is simply too little to make bear any quantitative significant in the field. It is also noteworthy that the research by Stahl et al. (2017) used students as the study participants. The use of students is considered to be a quality hurdle as it doesn’t represent the same authenticity as if the participants are actual patients seeking treatment for low back pain in a medical health center.
Summary and conclusion
For the majority of the studies contained in this paper, they have studied only a single low back pain intervention. A combination of one, two, or more intervention would affect the general outcome, but the exact nature of this outcome is not clear. However, based studies included in this study, like, Guzmán et al. (2001), Patel et al. (2019), Dehghan et al. (2014), Taylor et al. (2019), Denneson et al. (2011), and Kim et al. (2015) it is obvious that combination of various pain management strategies does have a net beneficial effect in minimizing pain, as well as promoting patient preference to treatment.
On this basis, it is therefore concluded that the combination of non-narcotic medication with yoga stretches and heat/cold therapy would have a net positive effect in reducing pain as compared to the use of non-narcotic medication only. Moreover, these three interventions, non-narcotic medication, therapy, and yoga, all have a different mechanism through which they alleviate pain. Therefore, it is proposed that a combination of the three would work to alleviate pain as compared to each intervention administered separately. While non-narcotic medication works at the bio-level to alleviate pain, both therapy, and yoga work at the physio-social level to reduce pain, improve functionality, as well as alleviate depression through the social aspect of both therapy and yoga.
However, it is suggested that further research is needed to scientifically determine the effect of combining these interventions for veterans with low back pain. In practice, persons with low back pain are seeking a combination of these interventions, therefore, research would be vital to scientifically determine and qualify the net effect of the combination of these interventions on reducing pain, any side effects arising from the combination, and how veterans perceive the combination in terms of motivation and the preferred combination.
References
Bagg, M. K., Hübscher, M., Rabey, M., Wand, B. M., O’Hagan, E., Moseley, G. L., ... & O’Connell, N. E. (2017). The RESOLVE Trial for people with chronic low back pain: protocol for a randomized clinical trial. Journal of physiotherapy, 63(1), 47-48.
Chou, R., Deyo, R., Friedly, J., Skelly, A., Hashimoto, R., Weimer, M., ... & Grusing, S. (2017). Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Annals of internal medicine, 166(7), 493-505.
Dehghan, M., & FarahbOD, F. (2014). The efficacy of thermotherapy and cryotherapy on pain relief in patients with acute low back pain, a clinical trial study. Journal of clinical and diagnostic research: JCDR, 8(9), LC01.
Denneson, L. M., Corson, K., & Dobscha, S. K. (2011). Complementary and alternative medicine use among veterans with chronic noncancer pain—Journal of Rehabilitation Research & Development, 48(9).
Guzmán, J., Esmail, R., Karjalainen, K., Malmivaara, A., Irvin, E., & Bombardier, C. (2001). Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ, 322(7301), 1511-1516.
Hayden, J. A., Van Tulder, M. W., & Tomlinson, G. (2005). Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Annals of internal medicine, 142(9), 776-785.
Kim, E. J., Choi, Y. D., Lim, C. Y., Kim, K. H., & Lee, S. D. (2015). Effect of heating and cooling combination therapy on patients with chronic low back pain: study protocol for a randomized controlled trial. Trials, 16(1), 285.
Nitsure, P. V., Pathania, T. S., & Bilgi, T. A. (2014). Comparison of elastic resistance band exercises and yoga in physiotherapy students with chronic non-specific low back pain: a randomized clinical trial. Journal of Yoga & Physical Therapy, 5, 180.
Patel, H. D., Uppin, R. B., Naidu, A. R., Rao, Y. R., Khandarkar, S., & Garg, A. (2019). Efficacy and Safety of Combination of NSAIDs and Muscle Relaxants in the Management of Acute Low Back Pain. Pain and Therapy, 8(1), 121-132.
Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 166(7), 514-530.
Stahl, J., Brewer, K., & Meggs, W. (2017). Prochlorperazine/Diphenhydramine vs. Ketorolac for Treatment of Acute-on-Chronic Back Pain Exacerbations in the Emergency Department of, 3, 2.
Taylor, S. L., Hoggatt, K. J., & Kligler, B. (2019). Complementary and integrated health approaches: What do Veterans use and want. Journal of general internal medicine, 34(7), 1192-1199.
Williams, K., Abildso, C., Steinberg, L., Doyle, E., Epstein, B., Smith, D., ... & Cooper, L. (2009). Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. Spine, 34(19), 2066.
Total number of results
n = 247
Reviewed abstract
n = 147
Full articles reviewed
n = 39
Included articles
n = 12
Removed duplicates and irrelevant
n = 100
Excluded
n = 108
Excluded
n = 27