Lifestyle Medicine for Chronic Lower Back Pain: An Evidence-Based Approach

Abstract

Lower back pain is a leading cause of work absence and activity limitations globally, with a 60% to 85% lifetime chance of occurrence. This article highlights the role that lifestyle medicine plays in managing lower back pain as a cost-effective intervention strategy. It is suggested that lifestyle medicine strategies, such as incorporating whole foods and a plant-based diet, sustainable physical activity and mind-body exercises, restorative sleep, stress resiliency, awareness and mitigation of substance abuse and addiction, and establishing meaningful social networks and self-care strategies, be a part of managing chronic lower back pain.

Keywords

lower back pain lifestyle medicine physical activity exercise self-care

Factors that may influence pain include physical and emotional health, nature of the injury or illness, social environment or cultural upbringing, acuity or chronicity of the symptoms, memory, and personality.

Introduction

An individual has a 60% to 85% lifetime chance of experiencing lower back pain.¹ Based on sample interviews of the US civilian population in 2018, 31.6% of women and 28.0% of men aged ≥18 years reported having lower back pain in the past 3 months.² In 2014, a report³ in the Journal of Pain showed that “Activity-limiting low back pain, in particular, has a worldwide lifetime prevalence of approximately 39% and a similar annual prevalence of 38%.”^{(p. 570)} Also, a Clinical Practice Guideline by Delitto et al⁴ in 2012 reported that lower back pain is a leading cause of work absence and activity limitation throughout the world.

According to the Mayo Clinic health information resource on back pain,⁵ there is an increased risk of developing back pain as a result of factors such as advancing age, diseases (such as arthritis or cancer), excess body weight, improper lifting, lack of exercise, psychological conditions such as depression and anxiety, and smoking. Incorporating lifestyle medicine strategies into a clinical care program may help individuals suffering from chronic lower back pain. In the Lifestyle Medicine Handbook,⁶ the authors outlined 6 pillars of lifestyle medicine. The primary components included incorporating whole foods and a plant-based diet, exercise, restorative sleep, stress resiliency, awareness and mitigation of addiction, and establishing meaningful social connections. This article aims to review selected lifestyle interventions to treat and manage chronic lower back pain.

Basic Pain Science

The Taber’s Cyclopedic Medical Dictionary defines pain as “an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage.”^7(p.1735) Factors that may influence pain include physical and emotional health, nature of the injury or illness, social environment or cultural upbringing, acuity or chronicity of the symptoms, memory, and personality.⁷ Some causes of mechanical lower back pain include muscle strain, ligament sprain, herniated nucleus pulposus, osteoarthritis, spinal stenosis, spondylolisthesis, or scoliosis.⁸

The biological model of pain assumes that all pain has a distinct physiological cause. The current medical approach uses the Biopsychosocial Model of Pain because it incorporates the interaction between the biological, psychological, and sociocultural variables.⁹ Many of the Biopsychosocial Model of Pain variables are also components of lifestyle medicine (Table 1).^6,10

Table 1.

Components of the Biopsychosocial Model of Pain.^a

Biological influences • Nociception • Inflammation • Tissue pathology (such as joint, muscle, or organ)	Psychological influences • Coping • Stress • Catastrophizing • Mood and emotions (such as fear, anger, or anxiety)
Behavioral influences • Substance use • Exercise • Sleep • Diet	Sociocultural influences • Social support (such as family, friends, and coworkers) • Education • Income • Occupation • Cultural background

Adapted from Bartley et al,¹¹ Engel,¹² Loeser,¹³ and Sluka.⁹

Clinical Concepts

The focus on clinical care should target not only the latest therapeutic interventions, but also the manner in which the therapy is effectively delivered to the patient. Clinicians need to improve other aspects of clinical care, such as building a therapeutic alliance, including shared decision-making, motivational interviewing, and establishing interprofessional collaborations.

A therapeutic alliance is where clinicians and patients establish a collaborative and purposeful relationship. This professional bond can lead to positive therapeutic changes and may improve pain outcomes.¹⁴ In other words, the context of clinical interventions can enhance the therapeutic effect. A study in 2020 by Kinney et al¹⁵ showed that establishing a therapeutic alliance with patients may positively affect chronic musculoskeletal pain. For example, to build a therapeutic alliance, the clinician could allow the patient to be a part of the decision-making process, make the patient feel welcome with their words and actions, and minimize distractions during treatment.¹⁶ Other strategies to interact effectively with patients may include allowing sufficient time for empathetic dialogue, being attentive and sensitive to personal and cultural needs, and showing a genuine interest in their life circumstance.¹⁷

Shared decision-making, where the clinician and patient decide using the best evidence available and include the patient’s values and preferences into the decision-making process, may also help improve long-term therapeutic outcomes.^18-20 For example, besides providing treatment options for the patient, the clinician could explain the pros and cons of selected interventions and identify the patient’s treatment preferences. Furthermore, to improve decision making, the clinician could use phrases such as, “What if we try . . . ?”, “Would you consider trying . . . ?”, or “Would you be open to . . . ?”²¹

Another clinical strategy to treat patients with lower back pain is to use motivational interviewing to empower and motivate patients to change their behavior.²² This collaborative approach uses a goal-oriented communication style and pays attention to the language of change.^23,24 The 5 necessary communication skills used in motivational interviewing include^24,25 asking open-ended questions, affirming (or praising) a person’s good intentions or efforts, using reflective listening, summarizing the person’s situation, and finally, informing and advising the person. For example, an open-ended question may be phrased as, “How can I help you with your back pain?” To affirm or praise the person’s good intentions, the clinician could say, “You did a great job quitting smoking six weeks ago.” The health care professional could address reflective listening by stating to the patient, “I understand you feel overwhelmed with your current situation.” Additionally, the person’s situation can be summarized by the clinician as, “Let me see if I understand you so far. Your back pain started . . .” Some practitioners may end the motivational interviewing session with, “Did I miss anything?” before moving into the physical examination or intervention phase.

Engaging with different professionals in a collaborative approach can help patients, families, and caregivers receive quality care while enhancing a clinician’s knowledge and presence in the community and potentially reducing health care costs.²⁶ An article²⁷ in Medical Education Online concluded, “Given the importance of quality care outcomes and the recognition that collaborative practice improves these outcomes, interprofessional education should be a high priority for every training institution.” Some suggested strategies to improve interprofessional collaboration include attending interdisciplinary meetings and conferences, creating interdisciplinary rounds at hospitals and clinics, organizing biannual meetings in the community as “lunch and learn” opportunities, and finally, connecting with health care providers from a variety of professions on social media sites such as LinkedIn.²⁸

Finally, clinicians also need to be aware of a person’s readiness for change. To help a patient change a lifestyle behavior, such as to quit smoking or increase physical activity, it would be helpful to know if the person is ready and open to making changes. There is some evidence for using the Pain Stages of Change Questionnaire in assessing if a person is likely to join a self-management intervention program.²⁹ The readiness for change model is based on the Transtheoretical Model of Behavior Change or the Stages of Change Model.^30,31 One version of the model starts with the precontemplation stage, where the person is not considering changing behavior. The next stage is the contemplation stage, where the person is considering changes in their behavior and progresses to the preparation stage, where the person is ready to take action. The action stage, where the person is taking active steps to change their behavior, is the model’s next level. Finally, the maintenance stage is where the person is sustaining and maintaining changes and preventing a relapse.

Lifestyle Interventions

Evidence-based practice involves scientific research, clinical expertise, and patient values.³² This section will highlight selected scientific research using lifestyle interventions for managing chronic lower back pain. Table 2 provides a review of various nonpharmacological and conventional, integrative, educational, and novel intervention strategies for addressing back pain.

Table 2.

Review of Nonpharmacological Strategies for Lower Back Pain.

Conventional interventions
• Assistive devices (such as a cane or walker)³³
• Braces and supports³⁴
• Exercise (aerobic training)³⁵
• Exercise (strength training)³⁵
• Exercise (core stabilization)³⁶
• Exercise (motor control)³⁷
• Exercise (aquatic therapy)³⁸
• Manual therapy (such as joint manipulation, joint mobilization, soft-tissue mobilization, or muscle energy techniques)^39,40
• Kinesiotaping⁴¹
• Physical agents (such as electrical stimulation)⁴²
• Traction⁴³

Integrative interventions
• Acupuncture⁴⁴
• Aromatherapy⁴⁵
• Biofeedback⁴⁶
• Cognitive behavioral therapy⁴⁷
• Cupping⁴⁸
• Dry needling⁴⁹
• Gua sha⁵⁰
• Hypnosis⁵¹
• Music therapy⁵²
• Tui na⁵³

Educational interventions
• Back school⁵⁴
• Ergonomics guidelines⁵⁵
• Explain education⁵⁶
• Pain neuroscience education^57,58

Novel interventions
• Biomechanically-assistive garment⁵⁹
• Shoe orthotics⁶⁰
• Trunk exoskeletons⁶¹

A review⁴⁴ in the Annals of Internal Medicine indicated several nonpharmacological therapies for chronic lower back pain. Some of these evidence-based interventions include exercise, psychological therapies, multidisciplinary rehabilitation, spinal manipulation, massage, and acupuncture. However, the authors of this review point out that many of these interventions have low to moderate evidence, with usually short-term analgesic effects. For this reason, these approaches may not be broadly incorporated but used on a case-by-case basis in the clinical setting.

Why should clinicians use lifestyle medicine interventions for managing chronic lower back pain? A randomized controlled trial⁶² in the European Journal of Pain showed that healthy lifestyle interventions might be cost-effective and reduce medication and absenteeism costs. Furthermore, there is a movement to address lifestyle factors and empower patients with self-care strategies to manage pain and disease. Table 3 outlines the components of lifestyle medicine that can be used for addressing lower back pain. Other benefits of using lifestyle medicine include helping clinicians diversify their clinical practice to have more treatment options and improving therapeutic alliance and interprofessional collaborations.

Table 3.

Components of Lifestyle Medicine for Addressing Back Pain.^a

• Nutrition
• Exercise and physical activity (conventional exercises and mind-body movements)
• Sleep
• Stress resilience
• Substance use and addiction
• Social connections
• Self-care

Adapted from Frates et al⁶ and Rippe.¹⁰

Nutrition and Back Pain

Healthy eating patterns play a crucial role in not only reducing lower back pain but also reducing excess body weight, which is one of the risk factors for developing back pain. A randomized controlled trial⁶³ in Nutricion Hospitalaria looked at the effect of diet in patients with fibromyalgia who have lower back pain. The study combined core stabilization exercises with a lacto-vegetarian diet and found that it contributed to pain reduction and improved body composition. Furthermore, a study by Roffey et al⁶⁴ in the Spine Journal found that a 52-week medically supervised and nonsurgical weight loss program showed improvement in back pain and function.

As a part of an interprofessional collaboration program, the patient could consult with a culinary medicine⁶⁵ specialist or a registered dietitian in order to gain knowledge about the foundations of cooking to reduce pain and inflammation using foods.⁶⁶ The patient may also be counseled to try the Mediterranean diet for weight loss⁶⁷ or use a targeted diet that includes low glycemic foods to help modulate pain.⁶⁸

Conventional Exercise, Physical Activity, and Back Pain

Clinicians understand the value of physical activity in helping prevent and treat a variety of medical conditions. Conventional exercises that include aerobic, strength, flexibility, and balance training may help patients improve endurance, increase core strength, loosen tight muscles, and improve coordination and stability. A systematic review⁶⁹ in the British Journal of Sports Medicine showed that leisure-time physical activity may reduce the risk of lower back pain. In 2015, Searle et al⁷⁰ concluded that resistance and stabilization exercises were beneficial for treating chronic lower back pain. The key is to help patients find meaningful and sustainable physical activities or exercises. For example, one patient may find walking, hiking, or biking enjoyable, whereas another person may prefer dancing, swimming, or weight training.

Mind-Body Exercises and Movements

Mind-body or integrative movements may be another form of exercise or physical activity. This type of exercise combines specialized movements, controlled breathing, and mental focus to improve overall health, balance, flexibility, and strength.⁷¹ Mind-body movements may include yoga, tai chi, qigong, and Pilates.

Yoga is a system of physical postures and coordinated diaphragmatic breathing that originated in India.⁷ A randomized noninferiority trial⁷² in the Annals of Internal Medicine concluded that a yoga program for nonspecific chronic lower back pain was noninferior to physical therapy for pain. An earlier systematic review by Cramer et al⁷³ found moderate evidence for yoga’s effectiveness for individuals suffering from chronic lower back pain.

Tai chi is a traditional Chinese martial art that uses a series of slow, controlled movements to improve balance, strength, flexibility, relaxation, and mental concentration.⁷ A randomized controlled trial⁷⁴ in Medicine concluded that tai chi alone or along with physical therapy may be beneficial for individuals with lower back pain. Another randomized study by Liu et al⁷⁵ found that tai chi reduced lower back pain in adults aged 50 years and older.

Qigong is an ancient Chinese practice that uses movement, breathing exercises, relaxation, and meditation.⁷ In 2019, Li et al⁷⁶ concluded that a type of qigong called Baduanjin was effective for lower back pain. Another systematic review⁷⁷ in the Journal of Clinical Medicine found that mindful exercises such as qigong and tai chi may be beneficial for managing chronic lower back pain.

Pilates is a bodywork system created by Joseph Pilates that uses specialized equipment or mat exercises to improve strength, flexibility, balance, and mental concentration. Randomized controlled trials in 2017 and 2018 by Cruz-Diaz et al^78,79 reported that a Pilates intervention effectively managed chronic lower back pain.

Sleep and Back Pain

Clinicians need to be better informed about sleep hygiene guidelines because sleep quality may affect individuals with lower back pain. A review article⁸⁰ in Physical Therapy stated that “Stress and sleep are consistently interconnected, as evidenced in numerous studies reporting strong associations between anxiety levels and insomnia severity, such as in people with chronic low back pain.”^{(p. 328)} In practical terms, guiding patients in restorative sleep strategies may be a significant intervention in some instances. For example, sleep hygiene guidelines may include helping a patient create a sleep-friendly environment, which includes a comfortable room (dark, quiet, and cool) and bed, in addition to using a supportive pillow, embracing mindfulness, and minimizing bright light and intense activities (such as exercise or television) near bedtime.

Furthermore, appropriate light exposure through outdoor light and sunshine is especially essential in the morning on awakening and during the day because it is necessary to improve sleep quality, mood, alertness, cognition, and reaction time and prevent depression.⁸¹ A randomized controlled trial in 2014 by Leichtfried et al⁸² reported that “light therapy even in low dose could improve depressive symptoms and reduce pain intensity in chronic nonspecific back pain patients.” Strategies that may increase natural light exposure include having breakfast near a window or on a balcony, porch, or patio, sitting near a window at work, going for an outdoor walk at lunch, working in a garden, including more outdoor activities, and remodeling the home to add more windows or skylights.

Stress and Back Pain

A study by Herman et al⁸³ found that mindfulness-based stress reduction may be a cost-effective strategy for helping individuals with chronic lower back pain. There are many different mindfulness-based stress reduction techniques, such as diaphragmatic breathing,⁸⁴ square breathing (also known as box breathing),⁸⁵ mindfulness-based body scan,⁸⁶ and walking meditation.⁸⁷ The essential component of many of these strategies is to help the individual get their breath under control. Therefore, teaching patients breathing control may be a good start. For example, during a square breathing technique, the person could breathe in slowly for 3 s, pause the breath for 3 s at the end of the inhale, exhale slowly for 3 s, and finally, pause the breath for 3 s. This sequence could be repeated 2 to 10 times or longer to promote relaxation.

Substance Use, Addiction, and Back Pain

Yang et al⁸⁸ in Spine, among others,^89-92 showed that behavior-related factors, such as smoking and alcohol consumption, were associated with lower back pain. A cohort study⁹³ in the BMJ Open concluded that combining lifestyle behaviors of nonsmoking, moderate alcohol consumption, physical activity, and a healthy diet appeared to decrease the risk of lower back pain in women. More recently, Skillgate et al⁹⁴ found that healthy lifestyle behaviors may also be protective for men with lower back pain.

Social Connections and Back Pain

Individuals with lower back pain may find that workplace, financial, and social pressures can affect their ability to manage their condition.⁹⁵ For this reason, clinicians can help patients find counselors, social workers, or connections in their community to help them heal and recover. In 2020, a perspective article⁹⁶ in the New England Journal of Medicine identified several social-prescribing interventions, such as gym or exercise classes, art-based therapies, volunteer opportunities, self-help groups for specific conditions, parenting programs, and community activities that include gardening, cooking, and sports.

Self-care and Back Pain

Self-care and self-management strategies, such as ergonomic instructions, proper body mechanics, joint protection and energy conservation guidelines, self-massage, self-acupressure, flare-up management, and pain neuroscience education, may be useful techniques to help patients manage their back pain. For example, the patient may be advised to use variable sitting postures to migrate tissue loads in the hip and back region.⁹⁷ Also, instructions in proper body mechanics and joint protection guidelines⁹⁸ may help patients properly lift, push, pull, carry, and bend during activities of daily living. Furthermore, one energy conservation strategy⁹⁹ may advise a patient to alternate between difficult and easy tasks at home or work to avoid overloading muscles and joints.

Other simple self-care techniques may include teaching the patient self-massage and self-acupressure techniques^100,101 to reduce spasm and pain. Additionally, many patients with back pain could benefit from flare-up management education.¹⁰² This educational strategy would empower individuals to create their own “toolbox” of useful techniques and strategies to manage symptoms when flare-ups occur. Finally, some individuals may need pain management education or counseling.^57,103

Conclusions

Research supports the use of lifestyle medicine strategies outlined by the American College of Lifestyle Medicine (https://www.lifestylemedicine.org/) to manage lower back pain with low-cost nonpharmacological interventions. Clinicians should incorporate a plant-based diet, sustainable physical activity and mind-body exercises, restorative sleep, stress resiliency, awareness of substance abuse and addiction, establishing meaningful social networks, and self-care strategies. Also, using motivational interviewing, shared decision-making techniques, and interprofessional collaborations may help clinicians establish a therapeutic alliance with their patients to improve desired medical outcomes.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

Not applicable, because this article does not contain any studies with human or animal subjects.

Informed Consent

Not applicable, because this article does not contain any studies with human or animal subjects.

Trial Registration

Not applicable, because this article does not contain any clinical trials.

ORCID iD

Ziya Altug

References

Krismer

van Tulder

; Low Back Pain Group of the Bone and Joint Health Strategies for Europe Project. Strategies for prevention and management of musculoskeletal conditions: low back pain (non-specific). Best Pract Res Clin Rheumatol. 2007;21:77-91. doi:10.1016/j.berh.2006.08.004

QuickStats: Percentage* of adults aged ≥18 years who had lower back pain in the past 3 months,^† by sex and age group—National Health Interview Survey, United States, 2018. MMWR Morb Mortal Wkly Rep. 2020;68:1196. doi:10.15585/mmwr.mm685152a5

Deyo

Dworkin

Amtmann

, et al. Report of the NIH Task Force on research standards for chronic low back pain. J Pain. 2014;15:569-585. doi:10.1016/j.jpain.2014.03.005

Delitto

George

Van Dillen

, et al. Low back pain. J Orthop Sports Phys Ther. 2012;42:A1-A57. doi:10.2519/jospt.2012.42.4.A1

Mayo Clinic. Back pain. Accessed September 8, 2020. https://www.mayoclinic.org/diseases-conditions/back-pain/symptoms-causes/syc-20369906

Frates

Bonnet

Joseph

Peterson

. Lifestyle Medicine Handbook. Healthy Learning; 2019:14.

Venes

Taber’s Cyclopedic Medical Dictionary. 23rd ed. FA Davis; 2017:1735.

Magee

. Orthopedic Physical Assessment. 6th ed. Elsevier Saunders; 2014:560.

Sluka

. Mechanisms and Management of Pain for the Physical Therapist. 2nd ed. Wolters Kluwer; 2016:11.

10.

Rippe

. Lifestyle Medicine. 3rd ed. CRC Press; 2019:13.

11.

Bartley

Palit

Staud

Predictors of osteoarthritis pain: the importance of resilience. Curr Rheumatol Rep. 2017;19:57. doi:10.1007/s11926-017-0683-3

12.

Engel

GL.

The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129-136. doi:10.1126/science.847460

13.

Loeser

. Concepts of pain. In: Stanton-Hicks

Boaz

, eds. Chronic Low Back Pain. Raven Press; 1982:145-148.

14.

Fuentes

Armijo-Olivo

Funabashi

, et al. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Phys Ther. 2014;94:477-489. doi:10.2522/ptj.20130118

15.

Kinney

Seider

Beaty

Coughlin

Dyal

Clewley

The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: a systematic review of the literature. Physiother Theory Pract. 2020;36:886-898. doi:10.1080/09593985.2018.1516015

16.

Ferreira

Maher

Refshauge

Latimer

Adams

RD.

The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther. 2013;93:470-478. doi:10.2522/ptj.20120137

17.

Babatunde

MacDermid

MacIntyre

Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature. BMC Health Serv Res. 2017;17:375. Published correction appears in BMC Health Serv Res. 2017;17:820. doi:10.1186/s12913-017-2311-3

18.

Parsons

Harding

Breen

, et al. Will shared decision making between patients with chronic musculoskeletal pain and physiotherapists, osteopaths and chiropractors improve patient care? Fam Pract. 2012;29:203-212. doi:10.1093/fampra/cmr083

19.

Toupin-April

Barton

Fraenkel

, et al. Development of a draft core set of domains for measuring shared decision making in osteoarthritis: an OMERACT Working Group on shared decision making. J Rheumatol. 2015;42:2442-2447. doi:10.3899/jrheum.141205

20.

Moore

Kaplan

SL.

A framework and resources for shared decision making: opportunities for improved physical therapy outcomes. Phys Ther. 2018;98:1022-1036. doi:10.1093/ptj/pzy095

21.

Légaré

Adekpedjou

Stacey

, et al. Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database Syst Rev. 2018;(7):CD006732. doi:10.1002/14651858.CD006732.pub4

22.

Vong

Cheing

Chan

CC.

Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 2011;92:176-183. doi:10.1016/j.apmr.2010.10.016

23.

Miller

Motivational interviewing with problem drinkers. Behav Psychother. 1983;11:141-172.

24.

Miller

Rollnick

Motivational Interviewing: Helping People Change. 3rd ed. Guilford Press; 2013.

25.

Purath

Keck

Fitzgerald

CE.

Motivational interviewing for older adults in primary care: a systematic review. Geriatr Nurs. 2014;35:219-224. doi:10.1016/j.gerinurse.2014.02.002

26.

Perreault

Dionne

Rossignol

Morin

Interprofessional practices of physiotherapists working with adults with low back pain in Québec’s private sector: results of a qualitative study. BMC Musculoskelet Disord. 2014;15:160. doi:10.1186/1471-2474-15-160

27.

Bridges

Davidson

Odegard

Maki

Tomkowiak

Interprofessional collaboration: three best practice models of interprofessional education. Med Educ Online. 2011;16. doi:10.3402/meo.v16i0.6035

28.

Sangaleti

Schveitzer

Peduzzi

Zoboli

ELCP

Soares

CB.

Experiences and shared meaning of teamwork and interprofessional collaboration among health care professionals in primary health care settings: a systematic review. JBI Database System Rev Implement Rep. 2017;15:2723-2788. doi:10.11124/JBISRIR-2016-003016

29.

Carr

Moffett

Sharp

Haines

DR.

Is the Pain Stages of Change Questionnaire (PSOCQ) a useful tool for predicting participation in a self-management programme? Further evidence of validity, on a sample of UK pain clinic patients. BMC Musculoskelet Disord. 2006;7:101. doi:10.1186/1471-2474-7-101

30.

Kerns

Rosenberg

Jamison

Caudill

Haythornthwaite

Readiness to adopt a self-management approach to chronic pain: the Pain Stages of Change Questionnaire (PSOCQ). Pain. 1997;72:227-234. doi:10.1016/s0304-3959(97)00038-9

31.

Prochaska

DiClemente

CC.

Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983;51:390-395. doi:10.1037//0022-006x.51.3.390

32.

Fetters

Tilson

. Evidence Based Physical Therapy. F A Davis; 2012:2.

33.

O’Sullivan

Schmitz

Fulk

, eds. Ambulatory assistive devices: types, gait patterns, and locomotor training. In: Physical Rehabilitation. 6th ed. F A Davis; 2014:464-484.

34.

Boutevillain

Bonnin

Chabaud

, et al. Short-term pain evolution in chronic low back pain with Modic type 1 changes treated by a lumbar rigid brace: a retrospective study. Ann Phys Rehabil Med. 2019;62:3-7. doi:10.1016/j.rehab.2018.06.008

35.

Wewege

Booth

Parmenter

BJ.

Aerobic

vs.

resistance exercise for chronic non-specific low back pain: a systematic review and meta-analysis. J Back Musculoskelet Rehabil. 2018;31:889-899. doi:10.3233/BMR-170920

36.

Suh

Kim

Jung

Ryu

JS.

The effect of lumbar stabilization and walking exercises on chronic low back pain: a randomized controlled trial. Medicine (Baltimore). 2019;98:e16173. doi:10.1097/MD.0000000000016173

37.

Aasa

Berglund

Michaelson

Aasa

Individualized low-load motor control exercises and education versus a high-load lifting exercise and education to improve activity, pain intensity, and physical performance in patients with low back pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45:77-85. doi:10.2519/jospt.2015.5021

38.

Dundar

Solak

Yigit

Evcik

Kavuncu

Clinical effectiveness of aquatic exercise to treat chronic low back pain: a randomized controlled trial. Spine (Phila Pa 1976). 2009;34:1436-1440. doi:10.1097/BRS.0b013e3181a79618

39.

Ulger

Demirel

Tamer

The effect of manual therapy and exercise in patients with chronic low back pain: double blind randomized controlled trial. J Back Musculoskelet Rehabil. 2017;30:1303-1309. doi:10.3233/BMR-169673

40.

Louw

Puentedura

Schmidt

Zimney

. Integrating Manual Therapy and Pain Neuroscience. Orthopedic Physical Therapy Products; 2019:41-66.

41.

Lin

Zhu

Huang

Wang

Zeng

Zhang

Short-term effect of kinesiotaping on chronic nonspecific low back pain and disability: a meta-analysis of randomized controlled trials. Phys Ther. 2020;100:238-254. doi:10.1093/ptj/pzz163

42.

Jauregui

Cherian

Gwam

, et al. A meta-analysis of transcutaneous electrical nerve stimulation for chronic low back pain. Surg Technol Int. 2016;28:296-302.

43.

Bilgilisoy Filiz

Kiliç

Uçkun

Çakir

Koldaş Doğan

Toraman

. Mechanical traction for lumbar radicular pain: supine or prone? A randomized controlled trial. Am J Phys Med Rehabil. 2018;97:433-439. doi:10.1097/PHM.0000000000000892

44.

Chou

Deyo

Friedly

, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166:493-505. doi:10.7326/M16-2459

45.

Lakhan

Sheafer

Tepper

The effectiveness of aromatherapy in reducing pain: a systematic review and meta-analysis. Pain Res Treat. 2016;2016:8158693. doi:10.1155/2016/8158693

46.

Kent

Laird

Haines

The effect of changing movement and posture using motion-sensor biofeedback, versus guidelines-based care, on the clinical outcomes of people with sub-acute or chronic low back pain-a multicentre, cluster-randomised, placebo-controlled, pilot trial. BMC Musculoskelet Disord. 2015;16:131. doi:10.1186/s12891-015-0591-5

47.

Cherkin

Sherman

Balderson

, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA. 2016;315:1240-1249. doi:10.1001/jama.2016.2323

48.

Wang

Tang

, et al. The effect of cupping therapy for low back pain: a meta-analysis based on existing randomized controlled trials. J Back Musculoskelet Rehabil. 2017;30:1187-1195. doi:10.3233/BMR-169736

49.

Liu

Huang

Liu

, et al. Evidence for dry needling in the management of myofascial trigger points associated with low back pain: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2018;99:144-152.e2. doi:10.1016/j.apmr.2017.06.008

50.

Saha

Brummer

Lauche

, et al. Gua Sha therapy for chronic low back pain: a randomized controlled trial. Complement Ther Clin Pract. 2019;34:64-69. doi:10.1016/j.ctcp.2018.11.002

51.

Rizzo

RRN

Medeiros

Pires

, et al. Hypnosis enhances the effects of pain education in patients with chronic nonspecific low back pain: a randomized controlled trial. J Pain. 2018;19:1103.e1-1103.e9. doi:10.1016/j.jpain.2018.03.013

52.

Guétin

Coudeyre

Picot

, et al. Effect of music therapy among hospitalized patients with chronic low back pain: a controlled, randomized trial [in French]. Ann Readapt Med Phys. 2005;48:217-224. doi:10.1016/j.annrmp.2005.02.003

53.

Kong

Fang

Zhan

, et al. Tuina-focused integrative Chinese medical therapies for inpatients with low back pain: a systematic review and meta-analysis. Evid Based Complement Alternat Med. 2012;2012:578305. doi:10.1155/2012/578305

54.

Straube

Harden

Schröder

, et al. Back schools for the treatment of chronic low back pain: possibility of benefit but no convincing evidence after 47 years of research: systematic review and meta-analysis. Pain. 2016;157:2160-2172. doi:10.1097/j.pain.0000000000000640

55.

Kajiki

Izumi

Hayashida

Kusumoto

Nagata

Mori

A randomized controlled trial of the effect of participatory ergonomic low back pain training on workplace improvement. J Occup Health. 2017;59:256-266. doi:10.1539/joh.16-0244-OA

56.

Butler

Moseley

. Explain Pain. 2nd ed. Neuro Orthopaedic Institute; 2013:18-35.

57.

Bodes Pardo

Lluch Girbés

Roussel

Gallego Izquierdo

Jiménez Penick

Pecos Martín

Pain neurophysiology education and therapeutic exercise for patients with chronic low back pain: a single-blind randomized controlled trial. Arch Phys Med Rehabil. 2018;99:338-347. doi:10.1016/j.apmr.2017.10.016

58.

Louw

Puentedura

Schmidt

Zimney

. Pain Neuroscience Education. 2nd ed. Orthopedic Physical Therapy Products; 2018:394-498.

59.

Lamers

Yang

Zelik

KE.

Feasibility of a biomechanically-assistive garment to reduce low back loading during leaning and lifting. IEEE Trans Biomed Eng. 2018;65:1674-1680. doi:10.1109/TBME.2017.2761455

60.

Cambron

Dexheimer

Duarte

Freels

Shoe orthotics for the treatment of chronic low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 2017;98:1752-1762. doi:10.1016/j.apmr.2017.03.028

61.

Baltrusch

Houdijk

van Dieën

van Bennekom

CAM

de Kruif

AJTCM

. Perspectives of end users on the potential use of trunk exoskeletons for people with low-back pain: a focus group study. Hum Factors. 2020;62:365-376. doi:10.1177/0018720819885788

62.

Williams

van Dongen

Kamper

, et al. Economic evaluation of a healthy lifestyle intervention for chronic low back pain: a randomized controlled trial. Eur J Pain. 2019;23:621-634. doi:10.1002/ejp.1334

63.

Martínez-Rodríguez

Leyva-Vela

Martínez-García

Nadal-Nicolás

Effects of lacto-vegetarian diet and stabilization core exercises on body composition and pain in women with fibromyalgia: randomized controlled trial [in Spanish]. Nutr Hosp. 2018;35:392-399. doi:10.20960/nh.1341

64.

Roffey

Ashdown

Dornan

, et al. Pilot evaluation of a multidisciplinary, medically supervised, nonsurgical weight loss program on the severity of low back pain in obese adults. Spine J. 2011;11:197-204. doi:10.1016/j.spinee.2011.01.031

65.

LeBlanc-Morales

Culinary medicine: patient education for therapeutic lifestyle changes. Crit Care Nurs Clin North Am. 2019;31:109-123. doi:10.1016/j.cnc.2018.11.009

66.

Schell

Scofield

Barrett

, et al. Strawberries improve pain and inflammation in obese adults with radiographic evidence of knee osteoarthritis. Nutrients. 2017;9:949. doi:10.3390/nu9090949

67.

Mancini

Filion

Atallah

Eisenberg

MJ.

Systematic review of the Mediterranean diet for long-term weight loss. Am J Med. 2016;129:407-415.e4. doi:10.1016/j.amjmed.2015.11.028

68.

Rondanelli

Faliva

Miccono

, et al. Food pyramid for subjects with chronic pain: foods and dietary constituents as anti-inflammatory and antioxidant agents. Nutr Res Rev. 2018;31:131-151. doi:10.1017/S0954422417000270

69.

Shiri

Falah-Hassani

Does leisure time physical activity protect against low back pain? Systematic review and meta-analysis of 36 prospective cohort studies. Br J Sports Med. 2017;51:1410-1418. doi:10.1136/bjsports-2016-097352

70.

Searle

Spink

Chuter

Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clin Rehabil. 2015;29:1155-1167. doi:10.1177/0269215515570379

71.

National Cancer Institute. Mind body exercise. Accessed September 8, 2020. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/mind-body-exercise

72.

Saper

Lemaster

Delitto

, et al. Yoga, physical therapy, or education for chronic low back pain: a randomized noninferiority trial. Ann Intern Med. 2017;167:85-94. doi:10.7326/M16-2579

73.

Cramer

Lauche

Haller

Dobos

A systematic review and meta-analysis of yoga for low back pain. Clin J Pain. 2013;29:450-460. doi:10.1097/AJP.0b013e31825e1492

74.

Qin

Zhang

, et al. Effect of Tai Chi alone or as additional therapy on low back pain: systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 2019;98:e17099. doi:10.1097/MD.0000000000017099

75.

Liu

Yeung

Xiao

, et al. Chen-Style Tai Chi for individuals (aged 50 years old or above) with chronic non-specific low back pain: a randomized controlled trial. Int J Environ Res Public Health. 2019;16:517. doi:10.3390/ijerph16030517

76.

Liu

, et al. Baduanjin exercise for low back pain: a systematic review and meta-analysis. Complement Ther Med. 2019;43:109-116. doi:10.1016/j.ctim.2019.01.021

77.

Zou

Zhang

Yang

, et al. Are mindful exercises safe and beneficial for treating chronic lower back pain? A systematic review and meta-analysis of randomized controlled trials. J Clin Med. 2019;8:628. doi:10.3390/jcm8050628

78.

Cruz-Díaz

Romeu

Velasco-González

Martínez-Amat

Hita-Contreras

The effectiveness of 12 weeks of Pilates intervention on disability, pain and kinesiophobia in patients with chronic low back pain: a randomized controlled trial. Clin Rehabil. 2018;32:1249-1257. doi:10.1177/0269215518768393

79.

Cruz-Díaz

Bergamin

Gobbo

Martínez-Amat

Hita-Contreras

Comparative effects of 12 weeks of equipment based and mat Pilates in patients with chronic low back pain on pain, function and transversus abdominis activation: a randomized controlled trial. Complement Ther Med. 2017;33:72-77. doi:10.1016/j.ctim.2017.06.004

80.

Nijs

Mairesse

Neu

, et al. Sleep disturbances in chronic pain: neurobiology, assessment, and treatment in physical therapist practice. Phys Ther. 2018;98:325-335. doi:10.1093/ptj/pzy020

81.

Turner

Mainster

MA.

Circadian photoreception: ageing and the eye’s important role in systemic health. Br J Ophthalmol. 2008;92:1439-1444. doi:10.1136/bjo.2008.141747

82.

Leichtfried

Matteucci Gothe

Kantner-Rumplmair

, et al. Short-term effects of bright light therapy in adults with chronic nonspecific back pain: a randomized controlled trial. Pain Med. 2014;15:2003-2012. doi:10.1111/pme.12503

83.

Herman

Anderson

Sherman

Balderson

Turner

Cherkin

DC.

Cost-effectiveness of mindfulness-based stress reduction versus cognitive behavioral therapy or usual care among adults with chronic low back pain. Spine (Phila Pa 1976). 2017;42:1511-1520.

84.

Hopper

Murray

Ferrara

Singleton

JK.

Effectiveness of diaphragmatic breathing for reducing physiological and psychological stress in adults: a quantitative systematic review. JBI Database System Rev Implement Rep. 2019;17:1855-1876.

85.

Malchiodi

. Trauma and Expressive Arts Therapy: Brain, Body, & Imagination in the Healing Process. Guilford Press; 2020:373.

86.

Ussher

Spatz

Copland

, et al. Immediate effects of a brief mindfulness-based body scan on patients with chronic pain. J Behav Med. 2014;37:127-134.

87.

Banth

Ardebil

MD.

Effectiveness of mindfulness meditation on pain and quality of life of patients with chronic low back pain. Int J Yoga. 2015;8:128-133. doi:10.4103/0973-6131.158476

88.

Yang

Haldeman

Behavior-related factors associated with low back pain in the US adult population. Spine (Phila Pa 1976). 2018;43:28-34. doi:10.1097/BRS.0000000000001665

89.

Ferreira

Pinheiro

Machado

Ferreira

ML.

Is alcohol intake associated with low back pain? A systematic review of observational studies. Man Ther. 2013;18:183-190. doi:10.1016/j.math.2012.10.007

90.

Schmelzer

Salt

Wiggins

Crofford

Bush

Mannino

DM.

Role of stress and smoking as modifiable risk factors for nonpersistent and persistent back pain in women. Clin J Pain. 2016;32:232-237. doi:10.1097/AJP.0000000000000245

91.

Shiri

Karppinen

Leino-Arjas

Solovieva

Viikari-Juntura

The association between smoking and low back pain: a meta-analysis. Am J Med. 2010;123:87.e7-35. doi:10.1016/j.amjmed.2009.05.028

92.

Bryan

Wolfe

Morrow

Stephenson

Haskell

Bryan

AO.

Associations among back and extremity pain with alcohol, tobacco, and caffeine use among US Air Force Pararescuemen. J Spec Oper Med. 2015;15:66-71.

93.

Bohman

Alfredsson

Jensen

Hallqvist

Vingård

Skillgate

Does a healthy lifestyle behaviour influence the prognosis of low back pain among men and women in a general population? A population-based cohort study. BMJ Open. 2014;4:e005713. doi:10.1136/bmjopen-2014-005713

94.

Skillgate

Pico-Espinosa

Hallqvist

Bohman

Holm

LW.

Healthy lifestyle behavior and risk of long duration troublesome neck pain or low back pain among men and women: results from the Stockholm Public Health Cohort. Clin Epidemiol. 2017;9:491-500. doi:10.2147/CLEP.S145264

95.

Chou

Cicuttini

Urquhart

, et al. People with low back pain perceive needs for non-biomedical services in workplace, financial, social and household domains: a systematic review. J Physiother. 2018;64:74-83. doi:10.1016/j.jphys.2018.02.011

96.

Roland

Everington

Marshall

Social prescribing—transforming the relationship between physicians and their patients. N Engl J Med. 2020;383:97-99. doi:10.1056/NEJMp1917060

97.

McGill

. Low Back Disorders. 3rd ed. Human Kinetics; 2016:194-196.

98.

Sheon

Orr

. Appendix B: joint protection guide for rheumatic disorders. In: Sheon

Moskowitz

Goldberg

, eds. Soft Tissue Rheumatic Pain: Recognition, Management and Prevention. 3rd ed. Williams & Wilkins; 1996:357-363.

99.

Iversen

Westby

. Arthritis. In: O’Sullivan

Schmitz

Fulk

, eds. Physical Rehabilitation. 6th ed. FA Davis; 2014:1085-1088.

100.

Buttagat

Techakhot

Wiriya

Mueller

Areeudomwong

Effectiveness of traditional Thai self-massage combined with stretching exercises for the treatment of patients with chronic non-specific low back pain: a single-blinded randomized controlled trial. J Bodyw Mov Ther. 2020;24:19-24. doi:10.1016/j.jbmt.2019.03.017

101.

Murphy

Harris

Keshavarzi

Zick

SM.

Self-administered acupressure for chronic low back pain: a randomized controlled pilot trial. Pain Med. 2019;20:2588-2597. doi:10.1093/pm/pnz138

102.

Tan

Hodges

Costa

Ferreira

Setchell

Impact of flare-ups on the lives of individuals with low back pain: a qualitative investigation. Musculoskelet Sci Pract. 2019;43:52-57. doi:10.1016/j.msksp.2019.06.003

103.

Moseley

Butler

DS.

Fifteen years of explaining pain: the past, present, and future. J Pain. 2015;16:807-813. doi:10.1016/j.jpain.2015.05.005