Original Article
https://doi.org/10.12965/jer.1938490.245
Journal of Exercise Rehabilitation 2019;15(5):703-708
The impact of modified exercise and relaxation therapy on chronic lower back pain in office workers:
a randomized clinical trial
Ardalan Shariat1,*, Reza Alizadeh2, Vahideh Moradi3, Elahe Afsharnia1, Azadeh Hakakzadeh1, Noureddin Nakhsotin Ansari1,4,
Lee Ingle5, Brandon S. Shaw6, Ina Shaw6
Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
Department of Anesthesiology, AJA University of Medical Sciences, Tehran, Iran
3
Department of Orthotics and Prosthetics, Iran University of Medical Sciences, Tehran, Iran
4
Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
5
Department of Sport, Health & Exercise Science, University of Hull, Kingston-upon-Hull, UK
6
Department of Human Movement Science, University of Zululand, KwaDlangezwa, South Africa
1
2
This study aimed to evaluate the effectiveness of a modified package of
exercise therapy combined with relaxation on pain intensity, range of
motion (ROM), anxiety, and quality of life (QoL) in office workers with
chronic lower back pain. In this clinical trial, 72 office workers aged 20
to 50 years with chronic low back pain were randomized to one of four
groups including; group 1, exercise therapy; group 2, psychotherapy
(relaxation therapy); group 3, modified protocol (exercise therapy followed by relaxation therapy); group 4, control group (no intervention).
Participants exercised 3 times weekly for 6 weeks for 40–45 min of exercise/relaxation. Pain intensity, ROM, anxiety, and QoL were evaluated
at baseline, 6 weeks, and 12 weeks after the end of the intervention. Results showed significant decreases in pain intensity and anxiety in the
three experimental groups compared to the control group. The three in-
tervention groups indicated a significant decrease in pain intensity and
anxiety after 6 and 12 weeks. ROM significantly improved in the exercise therapy and the modified protocol over time (after 6 and 12 weeks).
A significant difference in QoL was found between the groups, with the
greatest improvement found in the psychotherapy and modified protocol groups. This therapeutic package (including exercise movements
and psychological interventions) was found to have a superior effect on
pain intensity, ROM, anxiety, and QoL after 6 and 12 weeks compared to
other interventions (only exercise and psychotherapy).
Keywords: Exercise therapy, Psychological, Low back pain, Office
workers
INTRODUCTION
may continue, intensify, and may ultimately lead to disability
(O’Sullivan et al., 2019). The high prevalence of lumbar-related
injuries can have a high impact at the individual level but also a
significant impact on healthcare services locally, regionally and
nationally (Natour et al., 2015; Richmond et al., 2015).
Due to prolonged sitting and inactivity in office workers, LBP
is a common cause of disability (Matsudaira et al., 2012). The economic burden of LBP is exponential and driven by the loss of productivity and early retirement (Shariat et al., 2017). Therefore,
understanding and identifying the factors that increase the risk of
Lower back pain (LBP) is a common condition which impacts
85%–90% of people in both developed and developing countries
(Asadi et al., 2016; Mehrdad et al., 2016; Mohseni-Bandpei et al.,
2017). Most people have experienced LBP at least once in their
lives, especially the nonspecified type defined as any low back
pain in the lumbar area, which is not related to a severe pathology
and is caused by unknown reasons (Maher et al., 2017; Synnott et
al., 2015). If individuals do not take their LBP seriously, the pain
*Corresponding author: Ardalan Shariat https://orcid.org/0000-0003-4750-5797
Sports Medicine Research Center, Neuroscience Institute, Tehran University of
Medical Sciences, Tehran 11489, Iran
E-mail: [email protected]
Received: August 20, 2019 / Accepted: September 18, 2019
Copyright © 2019 Korean Society of Exercise Rehabilitation
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/)
which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.
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pISSN 2288-176X
eISSN 2288-1778
Shariat A, et al. • Modified package of exercise therapy for chronic low back pain
LBP are necessary, while developing effective rehabilitation strategies for work-related LBP (Steffens et al., 2016). Research has
shown that LBP is a multifactorial disorder with several physical
and psychological risk factors. Physical factors include stature,
body mass, age and body mass index. Psychological factors include
mental fatigue, anxiety and depression (Stubbs et al., 2016; Yang
et al., 2016). In this regard, workplace stress can cause the lower
back muscles to spasm, and increase the incidence of LBP. This is
exacerbated by prolonged periods of sitting and general sedentariness in office workers (Hurwitz et al., 2005; Stubbs et al., 2016;
Synnott et al., 2016). Hence, both the physical and psychological
wellbeing of an individual with LBP needs to be addressed in the
management of LBP. Recently, new treatment methods based on
physical exercise have been proposed, but these methods generally
focus on the full length of the spine (Miyamoto et al., 2019; Shariat et al., 2018). Often the impact of psychological wellbeing is
not included in interventions. Therefore, the aim of the current
study is to modify a new therapeutic exercise protocol presented
by a recent research in 2017 (Shariat et al., 2018) with the purpose of representing an intervention that addresses both physical
and psychological wellbeing.
MATERIALS AND METHODS
The present study was a single-blind randomized control trial
with parallel groups. In this study, office workers with chronic
LBP were selected. Following ethical approval (IRCT20171111
037388N2, Tehran University of Medical Sciences), participants
provided full written consent prior to participation. The inclusion
criteria for enrollment was class 11, I American Society of Anaesthesiologists physical status classification, aged 20–50 years,
chronic LBP for more than 3 months with at least two symptoms
of chronic LBP including pain reported when lifting heavy loads
or feeling pain during changing postural position, absence of pain
in lower limb during physical testing, absence of disc tearing,
presence of low intensity pain signals between vertebral area, and
absence of joint burst following magnetic resonance imagining
(MRI). The participants were excluded if they used corticosteroids
or had symptoms (dizziness or unconscious feeling, paralysis) prior
to the start of the study. Each participant was evaluated by a qualified physician and underwent an MRI scan to determine the extent of damage in the lower back region.
Based on the randomized block design, participants were randomly assigned into one of four parallel study arms; group 1, exercise therapy; group 2, psychotherapy (relaxation therapy); group
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3, modified protocol (exercise therapy followed by relaxation therapy); group 4, control group (no intervention). Physical exercises
and relaxation techniques were shown to clinical staff via an instructional video. Participants were required to complete three
nonconsecutive sessions per week for 6 weeks, for 40–45 minutes
for each training session.
The physical exercise component included 13 simple exercise
movements that had to be performed 3 times a day for 10 repetitions. The exercises were derived from Williams and McKenzie
and followed the recommendations of the American College of
Sports Medicine. This protocol was previously introduced by Shariat et al. (2017) as an effective protocol for LBP. The relaxation
component was based on the stress management model, and followed guidance provided by Conrad et al. (2007). To perform this
test, participants were instructed to relax for 8 min while they sat
on a comfortable chair in a large room with appropriate light and
temperature without any noise. Participants were then asked to
breathe at their usual depth and rate and then for 4 min they were
required to inhale for a count of 10 and to exhale for a count of 10
while thinking of the word “relax.” During the test their eyes
were open and they were asked to breathe through their nose.
The modified protocol required the participants to perform the
relaxation training for 20–25 minutes. Each session was led by a
sports psychologist. This was followed by the physical exercise
component (Conrad et al., 2007).
Outcome measurements
The outcome measurements included the evaluation of quality
of life (QoL) using the QoL questionnaire (Burckhardt and Anderson, 2003), anxiety and depression using the hospital anxiety and
depression (HADS) questionnaire (Montazeri et al., 2003), the severity of pain based on the Functional Rating Index test (Ceran
and Ozcan, 2006) and the hips’ range of motion (ROM) using the
Thomas test before the treatment, at 6 weeks after the end of the
intervention, and 12 weeks following the intervention. Cronbach
alpha of the Iranian HADS questionnaire was obtained between
0.78 and 0.86 for anxiety and depression, respectively.
Sample size
The sample size was calculated separately for each dependent
variable, and the highest number was considered as the sample
size for our study. The sample size for each group was 28 participants with an additional 20% added due to likely attrition over
the 6-week intervention. As such, 34 participants were required
for each group.
https://doi.org/10.12965/jer.1938490.245
Shariat A, et al. • Modified package of exercise therapy for chronic low back pain
89 Assessed for eligibility
13 Excluded
76 Randomized
19 Allocated to exercise intervention
19 Allocated to psychotherapy intervention
19 Allocated to control group
19 Allocated to modified protocol
0 Lost at follow-up
2 Lost at follow-up
2 Lost at follow-up
0 Lost at follow-up
19 Analysis
17 Analysis
17 Analysis
19 Analysis
Fig. 1. Sampling framework of the study.
Data analysis
To evaluate the normality of the data, a Kolmogorove–Smirnove test was performed. The distribution of all of the variables was
normal. After evaluating the normality of data; ranges, means,
and standard deviations were reported and baseline characteristics
between groups were assessed by the independent t-test. For each
variable the main and interactive effects of group and time were
determined using a mixed model of analysis of variance. The data
analysis was carried out using IBM SPSS Statistics ver. 22.0 (IBM
Co., Armonk, NY, USA).
RESULTS
Of the 89 participants who volunteered for the study, 76 were
eligible to participate. Of the initial 76 participants, 72 (95%)
completed the study. Four participants did not complete the study
due to falling ill (Fig. 1).
No significant differences were found at baseline between the
four groups. Data revealed a significant improvement in the
ROM of the exercise therapy and modified protocol groups when
compared to the control and the psychotherapy groups. The results showed that there was a significant group-by-time interaction effect and a main effect for time (P
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