Low back pain (LBP) is a very common and often debilitating condition affecting hundreds of millions of people globally.

It is estimated that around 70 per cent of people who experience an episode of LBP will have a recurrence within 12 months, which adds to the disease and economic burden on individuals and society.

Dr Natasha Pocovi APAM and Professor Mark Hancock APAM, from the Department of Health Sciences at Macquarie University in Sydney, were part of a team of researchers from Australia and the Netherlands who completed the WalkBack trial between September 2019 and June 2022.

‘The primary focus of the study was on preventing back pain, knowing that most people who experience it will have a recurrence,’ says Mark.

While physiotherapists recommend exercise for those experiencing LBP, little research had been carried out to determine the effectiveness and cost-effectiveness of an accessible and low- cost intervention such as walking for preventing LBP.

A grant from the National Health and Medical Research Council presented the researchers with an opportunity to bring the WalkBack trial to fruition.

WalkBack was a randomised controlled trial with 701 participants (351 in the intervention group, 350 in the control group) who had recently recovered from an episode of non-specific LBP that had had an impact on daily activities and had lasted for more than 24 hours.

Participants in the intervention group had six sessions over six months with a physiotherapist, who worked with each individual to collaboratively develop a progressive walking program and supply education.

The intervention providers were given training (less than five hours) in the principles of health coaching to aid in the delivery of the intervention.

Participants in the control group received usual care (which is usually no care) but were free to seek out treatment or prevention strategies as required.

The primary outcome was the number of days until participants experienced an activity-limiting recurrence of LBP, with participants followed for a minimum of 12 months and up to 36 months.

For the purposes of the study, recurrence was defined according to three different criteria: the episode of LBP had at least moderate impact on daily life (primary outcome), it led people to seek care and it was more than two out of 10 on a pain scale for over 24 hours.

‘Much of our effort as physiotherapists goes towards treating LBP but for our research, we believed that if we pivoted our focus towards prevention, it could have a massive impact on patients’ lives, the healthcare system and how we manage recurrent pain,’ says Natasha.

‘We know that behaviours can be difficult to change, particularly behaviours related to physical activity, and that just prescribing a walking program was unlikely to be enough; that’s why we felt it was also important to include a physio to help develop an individualised program and provide ongoing support and education as well some accountability for the intervention participants.’

Twenty-four physiotherapists from private clinics across Australia were recruited.

They used participants’ health data (such as current level of walking, age, comorbidities and body mass index), information about environmental barriers (such as safety, lighting or surfaces) and health coaching approaches to inform an appropriate and individualised starting dose of walking and progress the program over 12 weeks.

After five sessions in those initial 12 weeks, there was a follow-up session at six months for reinforcement.

The physiotherapists were able to reassure the participants by educating them about our modern understanding of LBP; while guidelines have changed, many outdated messages related to bed rest and activity causing more harm are still pervasive.

During the trial, however, COVID-19 made an appearance.

Among the many problems it caused, there were also some fortuitous flow-on effects. ‘COVID actually opened up the whole country to the study and intervention,’ says Mark.

‘We had to move everything online but the physios enjoyed it because it made the focus on self-management even clearer for patients and we were able to recruit participants from some very rural and remote parts of the country, where this care would otherwise be inaccessible.’

On average, participants had experienced 30 episodes of LBP prior to entering the study.

Natasha says, ‘Many participants believed that movement was bad, that they’d increase their chances of a recurrence by walking.

'We spent time informing the physios about how to speak with patients and ease their concerns about exercise.

'Not all participants were convinced that something as simple as walking could completely eradicate LBP but over time many reported that if they did have a recurrence, they recovered more quickly and found the episodes to be less disabling than before.

'Plus there were other benefits like weight loss, better management of comorbidities, improved sleep and reduced stress.’

The primary outcome of reducing an activity-limiting recurrence of LBP was achieved in the intervention group, with a statistically significant 28 per cent reduction in the risk of recurrences.

The median days until a recurrence of LBP was 208 days in the intervention group and 112 days in the control group.

The intervention was also found to be cost-effective, with the largest financial benefits seen in a reduction of work absenteeism related to LBP.

While the number of participants experiencing an adverse event was similar across the intervention and control groups (183 versus 190), those in the intervention group experienced a greater number of adverse events related to the lower extremities (100 versus 54), such as knee pain and plantar fasciitis.

This could be attributed to the increased amount of walking performed by the intervention group.

‘In the medium to long term, there is a reasonable chance that the walking may actually help these lower extremity conditions but we do not have data on adverse events in the long term with which to assess this.

'As we initially load tissues, we may sometimes experience short-term soreness but in the longer term have less soreness and pain than if we’d never started the exercise,’ says Mark.

‘Many studies have been done on exercise and education for LBP but the exercise component has been largely inaccessible to patients, due to the need for equipment, close clinician supervision and a large number of sessions—all of which incur a significant cost to the patient,’ says Natasha.

‘If exercise and education are the key, we wondered if we could facilitate that in a way that’s low-cost, simple and accessible and that almost anyone can engage with.’

Part of the success of the trial for participants could be attributed to its individualised design and to empowering patients to manage their own condition.

‘Physios and other clinicians often deliver treatments to patients, so we tipped who had the power and encouraged patients to decide what the program would look like,’ says Mark.

‘Patients also had someone to be accountable to and they reported that this was helpful, especially early on in the program.’

‘There’s an opportunity to move away from focusing on treatment alone and instead look at the potential of prevention and of equipping our patients with self-management skills to improve how we tackle LBP,’ Natasha says.

‘Physios played a pivotal role in the intervention, acting as health coaches.

'Some patients may have the knowledge and motivation to start a walking program independently and have good outcomes but our study suggests that the support role of the physiotherapist and the education they provided were important to the positive outcomes.’

The reaction to the study has been overwhelming, with publication in The Lancet soon followed by worldwide media attention including from The New York Times, The Guardian and the BBC as well as podcast invitations and television interviews.

‘The coverage we’ve had has been enormous and I think it surpassed what a lot of people expected,’ says Natasha.

‘We’ve heard stories of people saying that they heard a young lady on the television talking about how walking could help with LBP and then starting walking as a result.

'It’s been great to see the immediate impact of our work.’

‘We see this as a fantastic opportunity, not only to spread the findings from this study but also to communicate the big-picture messages about LBP and pain generally,’ adds Mark.

‘We think it’s an important story—it’s applicable to so many people.

'Researchers have been trying for a long time to encourage community understanding of these key messages, especially about increasing activity being good for many pain conditions including back pain.

'There’s obviously some tension there because we’d like the intervention to be delivered with some physiotherapist involvement but that may limit the accessibility somewhat.’

The researchers acknowledge that while the study had many strengths, such as the high follow-up rates for participants over 12 to 36 months, there were also some limitations.

‘We can’t be certain how well our findings generalise to people who are different from those we included.

'Most participants were in their mid-50s and generally well educated,’ says Natasha.

‘So it’s difficult to know if it would work similarly in younger people with lower levels of formal education.’

Conversely, the relatively high number of physios involved in the study was a positive.

Mark says, ‘We included 20-plus clinicians working in multiple states in face-to-face and telehealth modes, which helped to increase the generalisability of the study.’

There are now plans to expand the WalkBack trial in a number of ways.

‘We’re confident that we’ve found an effective intervention and would like to see it rolled out into clinical practice but what that looks like is still a bit of a question mark for us,’ says Natasha.

‘We’re optimistic about WalkBack’s effectiveness in different populations,’ adds Mark, ‘but we want to test that to confirm.’