The effect of aquatic and land exercises on pain, health related quality of life, kinesiophobia and disability in chronic low back pain: A randomized clinical trial

Author(s): Nilay Çömük Balci*, Ayça Aytar, Emine Atici, Gülen Takin, Mustafa Gülen and Mert Demirsoz Background: This study aims to compare the effectiveness between aquatic exercise interventions and land-based exercises in the treatment of Chronic Low Back Pain. Methods: Thirty patients were randomly allocated to land exercise (n=15) and aquatherapy group (n=15). Both groups underwent Hot pack, conventional TENS, and continuous ultrasound. A water-based exercise ... Abstract View Full Article View DOI: 10.17352/2455-5487.000082


Introduction
Low Back Pain (LBP) is a common musculoskeletal occupational health problem and the leading specifi c cause of years lived with disability [1]. Between 75% and 85% of the population will experience some form of low back pain during their lifetime [2]. LBP can be classifi ed into three categories: acute, subacute, and chronic. In most cases (90%) pain is resolved within 12 weeks without long-term impairment.
Chronic Low Back Pain (CLBP) accounts for the remaining 10% of the cases and is responsible for the majority of the associated economical burden [3,4]. It is also one of the leading causes of morbidity and works absenteeism and therefore, cost-effective strategies used to treat this condition are important [5].
Numerous studies have demonstrated the favorable effects of rehabilitative exercise on reducing chronic (longer than three months) LBP [6,7]. Exercise helps to develop core stability and increases range of motion. A combination of aerobic, strength, and stretching exercises have been reported to be more effective in treating LBP than leaving it untreated [8]. Evidence has shown that exercise can decrease pain, disability, time off work, and the increase quality of life in patients with chronic low back pain [9,10].
Many types of physical treatment are recommended for the management of pain and disability in patients with chronic low back pain [11]. Aquatic therapy has been used for many years in the management of musculoskeletal problems including low back pain. Water immersion decreases axial loading of the spine and, through the effects of buoyancy, allows the performance of movements that are normally diffi cult or impossible on land [12]. Aquatic therapy is also used to manage additional benefi ts in the treatment of pain, disability, and quality of life in chronic low back pain [13].
The recent guidelines for the management of patients with CLBP recommend supervised exercise therapy as a fi rst-line treatment for the reduction of pain and disability [14]. The aim of this study is to compare the effectiveness of aquatic exercise interventions with land-based exercises in the treatment of CLBP.

Research design
This study was conducted at a University Hospital Physical Medicine and Rehabilitation Outpatient clinic. All patients provided written informed consent before the study began.
This study was approved with the permission of the university social and humanities and arts research board (Project no:62310886-600).
The inclusion criteria for the patients were to be age ranging between 20 and 65, and each patient had to be diagnosed with clinical examination and radiological fi ndings of low back pain from at least 6 months.
All patients who had spinal stenosis and mechanical lumbar pain for 3 months, had lumbar spine surgery before the intervention, had a progressive neurological loss, was pregnant, had umbilical, hiatal, inguinal hernia and active hemorrhoids, primary or metastatic spinal malignancy, infectious spondylodiscitis such as tuberculosis, brucella, infl ammatory spondylitis, advanced osteoporosis, severe pulmonary and cardiovascular disease and patients who had previously undergone traction therapy were all excluded from the study. The pain was assessed at rest and at movement by using a 10-cm-long visual analog scale (0 means no pain while 10 means worst pain [14]. For disability assessment, the Modifi ed Oswestry Disability İndex was used [15]. Quality of life was assessed by the Short-Form 36 Health Survey (SF-36) [16]. The assessment of kinesiophobia was made with the Tampa Scale [17].

Statistical analysis
The power of analysis was conducted by G*Power 3.0.10,

Results
There were no statistically signifi cant differences in the demographic features between the groups (Table 1) Evaluation of the d-value between pre and after-therapy of the two groups is given in Table 3.

Discussion
The present study shows no signifi cant differences between aquatic and land exercises on back pain, disability,  [13,23,24]. In our study, we also found a signifi cant decrease in pain in both aquatic and land exercise groups but we found no difference between aquatic and land exercises. This may be due to the fact that the other studies had a control group while we had two different exercise groups besides conventional physical therapy including thermotherapy and electrotherapy in both of our groups. Also, there is heterogeneity about no standard guidelines exist for aquatic exercises in chronic low back pain, particularly regarding the number of sessions and duration and frequency. In our study, patients received a program with a three-days per week frequency as like on land exercises. Similar to our study Sjogren, et al. studied subjects with chronic low back pain. Patients were allocated to either hydrotherapy treatment or land treatment groups. They attended their respective group sessions twice weekly for 6 weeks. At the end of the study, results indicated that both groups improved signifi cantly in functional ability and in decreasing pain levels [25]. But, overall there was no signifi cant difference found between the 2 types of treatment. Recently, Carayannopoulos, et al. suggested combining both water and land modalities, which enhance the benefi ts of exercise synergistically [26].  [13,23,27,28].
The other difference in our study was the decrease in pain during an activity in the aquatherapy group after treatment. This may be due to the type of exercises and environmental factors in water that made a difference in aquatic exercises. In aquatic exercise group the whole body enrolled in the therapy sessions and maybe mobility and strength of the whole body has improved which concluded as a decrease in pain during activity.
It is theorized that for some individuals with chronic low back pain, negative beliefs about pain and/or negative illness information lead to a catastrophizing response in which the worst possible outcome of the activity is imagined. This leads to fear of activity and avoidance that in turn causes disuse and resultant distress, reinforcing the original negative appraisal in a deleterious cycle [29]. Ishak, et al. concluded that kinesiophobia predicted mobility and balance in older persons with low back pain. Kinesiophobia should be continuously assessed in clinical settings to recognize the obstacles that may affect patient's compliance towards a rehabilitation program in low back pain [30]. Osumi, et al. also found evidence of a particular lumbar movement pattern associated with kinesiophobia. Thus, psychological factors impact lumbar movement patterns in individuals with chronic low back pain [31]. There are several studies for the management of kinesiophobia in chronic low back pain [32][33][34][35]. To our knowledge, this is the fi rst study that evaluated the effect of aquatic exercises on kinesiophobia in low back pain. In our study, we observed no difference between aquatic exercises and land exercises in terms of kinesiophobia. In land exercises, signifi cant improvements were found in kinesiophobia in the evaluation between before and after treatment. Table 3: Evaluation of the d-value between pre and after-therapy of the two groups.

Conclusion
The fi ndings from this study show similar benefi t of aquatic exercises and land exercises on pain, disability, health-related quality of life and kinesiophobia in chronic low back pain, even land exercises has a signifi cant effect in emotional role domain of health related quality of life. Further studies with a larger sample size with long-term outcomes are needed to confi rm these fi ndings.