Background & Aims

Low back pain is the leading cause of global disability [1]. Exercise reduces pain and disability for chronic low back pain (CLBP). However, at intermediate and long-term follow-ups, the benefits of exercise on pain and disability are no longer clinically meaningful [2]. Adherence to exercise is likely an important factor influencing the diminishing benefits of exercise for CLBP over time, with 70% of people with CLBP reporting they do not adhere to prescribed home exercises [3]. To improve the long-term efficacy of exercise treatment, it is important to gain a better understanding of the factors which influence exercise adherence in people with CLBP.

This systematic review of qualitative studies aims to identify the barriers and enablers to exercise adherence from the perspective of individuals with CLBP. The findings from this study will be used refine exercise interventions for people with chronic low back pain to improve adherence.

Methods

We searched CENTRAL, EMBASE, CINAHL, SPORTDiscus, PubMed, PsycINFO, CINAHL, and Scopus databases from inception to 28th February 2023 for studies that qualitatively explored the factors influencing exercise adherence for adults with chronic low back pain. All qualitative data on barriers and enablers to exercise adherence was extracted. A hybrid approach was used to analyze data, combining inductive thematic synthesis [4] with a deductive approach using the Theoretical Domains Framework of behaviour change [5]. We assessed methodological quality using the Critical Appraisal Skills Programme checklist [6] and the level of confidence of the findings using the Confidence in the Evidence from Reviews of Qualitative Studies [7]. We maintained a reflexive stance, reporting our biases to ensure that barriers and enablers were reported transparantly. We reported our findings in accordance with the Enhancing transparency in reporting the synthesis of qualitative research guidelines [8].

Results

Overall, 12,972 studies were screened at title and abstract level. We then screened 70 full texts for eligibility and included 23 papers. with 677 participants (62% female, 18-97 years old). Exercise experiences included: a trial intervention, professionaly prescribed, self exercise or no exercise. Four themes were identified across the data: 1) Exercise, pain and the body, 2) Psychological factors, 3) Social factors and 4) External factors. Within these themes there were 16 sub-themes: pain changes, other comorbidities, physiological effects of exercise, wellbeing, self-efficacy, motivation, exercise value, health beliefs, enjoyment, advice, support, soical environment, logistical factors, accessibility and physical environment. Sub-themes were predominantly (15/16) comprised of both barriers and enablers to exercise adherence. Most papers had very minor (12/23) or minor (7/23) methodological limitations and all themes were judged as having moderate or high certainty evidence.

Conclusions

This systematic review identified and synthesised all available qualitative evidence concerning barriers and enablers to exercise adherence from the perspectives of individuals with CLBP. It is the most up to date review in this field. The review had two notable findings. Firstly, 15 out of 16 sub-themes consisted of both barriers and enablers to exercise adherence. This pointed towards a reconceptualization of barriers and enablers, showing that they were more appropriately represented on a spectrum rather than being simple dichotomous variables. Secondly, different barriers and enablers were experienced at distinct times in relation to completing exercise: pre, during or post. Specifically, the pre-exercise stage was reported as having the most barriers and enablers. The findings of this review were informed by studies with predominantly few methodological limitations and the findings were graded as having moderate to high certainty.

References

[1] Ferreira ML, et. al. Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. The Lancet Rheumatology 2023;5(6):e316-e329.
[2] Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews 2021(9).
[3] Beinart NA, Goodchild CE, Weinman JA, Ayis S, Godfrey EL. Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: a systematic review. Spine J 2013;13(12):1940-1950.
[4] Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008;8:45.
[5] Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, Foy R, Duncan EM, Colquhoun H, Grimshaw JM, Lawton R, Michie S. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Science 2017;12(1):77.
[6] Critical Appraisal Skills Programme (2018). CASP Qualitative Checklist Available at: https://casp-uknet/images/checklist/documents/CASP-Qualitative-Studies-Checklist/CASP-Qualitative-Checklist-2018pdf Accessed 14/04/2023.
[7] Lewin S, Booth A, Glenton C, Munthe-Kaas H, Rashidian A, Wainwright M, Bohren MA, Tunçalp Ö, Colvin CJ, Garside R, Carlsen B, Langlois EV, Noyes J. Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series. Implementation Science 2018;13(1):2.
[8] Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Medical Research Methodology 2012;12(1):181.

Presenting Author

Yannick Gilanyi

Poster Authors

Yannick Gilanyi

BSc(Hons)

Neuroscience Research Australia

Lead Author

Brishna Shah

Bachelor of Exercise Physiology (Hons)

Lead Author

Aidan Cashin

Neuroscience Research Australia

Lead Author

Mitchell Gibbs

PhD

Lead Author

Jessica Bellamy

Bachelor of Exercise Physiology

Lead Author

Richard Day

Bachelor of Medicine and Bachelor of Surgery

Lead Author

James McAuley

Neuroscience Research Australia, Universidade New South Wales,

Lead Author

Matthew Jones

PhD

University of New South Wales

Lead Author

Topics

  • Specific Pain Conditions/Pain in Specific Populations: Low Back Pain