Walking Programs: An Integral Part Of Multi-Disciplinary Pain Management
Matthew Richards, APA Pain Physiotherpist
Chronic pain conditions are a significant cause of disability. Low back pain, for example, was one of the top 10 contributors to increasing health loss worldwide over the 30 years to 2019 (GBD 2019). Evidence-based interventions to enhance mobility and well-being are therefore important, and there is a significant bank of evidence that exercise is effective for pain and function in the treatment of chronic low back pain (Hayden et al. 2021). Exercise is recommended in treatment guidelines for this condition (Lin et al., 2019; Oliveira et al., 2018). More specifically, exercise and activity that is steadily increased in a graded way over time is a common cognitive-behavioural approach, also recommended for people with low back pain (Foster et al. 2018). Graded exercise is further explored in a 2023 article written by Physiotherapist, Mat Foreman from Advance Healthcare.
When considering an appropriate exercise or activity upon which to build a rehabilitation program, it can help to consider something functionally important to the individual, and a walking program is often appropriate. Walking may not seem an obvious choice of exercise when compared with other exercises commonly prescribed for back pain, however a walking program is suppaorted by robust research evidence.
A systematic review examining links between daily step counts and disease found with each 1000 daily step count increase there was a significant reduction in all-cause mortality (6-36%) and cardiovascular disease (5-21%), and health benefits were identified even when walking less than 10,000 steps per day (Hall et al., 2020). We also know that studies of structural brain MRI show physical activity is associated with larger volumes in brain regions vulnerable to dementia (Domingos et al., 2021). So finding time for even a short walk, perhaps at lunch time, may be beneficial for your cardiovascular and mental health.
Figure: "Effect of exercise for depression" from article by Noetel et al., 2024
In a recent systematic review (Noetel et al., 2024) various forms of exercise were shown to be beneficial for depression. Programs of walking or jogging when compared with other active treatments were shown to be most beneficial (see figure above for the list of exercise types studied and statistical analysis data). Also, a greater intensity of exercise increased its effectiveness for depression (Noetel et al., 2024). This adds support for building exercise intensity over time, such as progressing a walking program to incorporate jogging or running in a manageable way, if this is a goal of the individual. Nature walks may also be of benefit for state anxiety (a form of anxiety which is temporary and related to adverse situations in a specific moment) (Kotera et al., 2021), so walking in a natural environment such as a local park or in the bush may have added benefits. Further research with larger samples is required to confirm benefits for other mental health conditions.
Physiotherapists, either as individual practitioners or as members of multi-disciplinary pain management teams, play a pivotal role in advocating and tailoring walking programs. Their expertise ensures the safety, progression, and alignment of programs with set rehabilitation and long-term (6-12 months) goals, for example, being able to complete the supermarket shopping or walk the dog along an undulating trail for an hour. Furthermore, physiotherapists may provide education on gait mechanics, pacing strategies, and pain management techniques, empowering individuals to engage in walking activities confidently.
Here is a more specific example. Mr G has experienced chronic pain for most of a year, such that he no longer walks regularly with a friend or plays social cricket. Both physical activity and socialisation levels have decreased, impacting his physical and mental health. Deconditioning and lower mood levels have resulted in typical daily walking being avoided. Following a physiotherapy assessment, it was identified that a 10-minute walk twice daily was not likely to be harmful, despite feeling discomfort at the time. Once performed routinely, monitored and increased in a graded way, the walking program was able to progress back to the social walking routine Mr G previously enjoyed. In the longer term, improved physical conditioning together with less interference from pain enabled harder exercises and activities of higher intensity such as jogging and an eventual return to sport.
In conclusion, the integration of physiotherapy-recommended walking programs into pain management regimens represents an evidence-based approach to improving physical function and reducing pain severity in individuals with chronic pain conditions.
References
Domingos, C., Pêgo, J. M., Santos, N. C. (2021). Effects of physical activity on brain function and structure in older adults: A systematic review. Behavioural brain research, 402, 113061. https://doi.org/10.1016/j.bbr.2020.113061
Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., . . . Maher, C. G. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet, 391(10137), 2368-2383. doi:10.1016/s0140-6736(18)30489-6
GBD 2019 Diseases and Injuries Collaborators. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet (London, England), 396(10258), 1204–1222. https://doi.org/10.1016/S0140-6736(20)30925-9
Hall, K.S., Hyde, E.T., Bassett, D.R. et al. Systematic review of the prospective association of daily step counts with risk of mortality, cardiovascular disease, and dysglycemia. Int J Behav Nutr Phys Act 17, 78 (2020). https://doi.org/10.1186/s12966-020-00978-9
Hayden, J.A., Ellis, J., Ogilvie, R., Malmivaara, A., van Tulder, M.W. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD009790. DOI: 10.1002/14651858.CD009790.pub2.
Kotera, Y., Lyons, M., Vione, K.C., Norton, B. Effect of nature walks on depression and anxiety: a systematic review. Sustainability 2021, 13, 4015. https://doi.org/10.3390/su13074015
Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., . . . O'Sullivan, P. P. B. (2019). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. doi:10.1136/bjsports-2018-099878
Noetel, M., Sanders, T., Gallardo-Gómez, D., Taylor, P., del Pozo Cruz, B., van den Hoek, D. et al. Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials BMJ 2024; 384 :e075847 doi:10.1136/bmj-2023-075847
Oliveira, C. B., Maher, C. G., Pinto, R. Z., Traeger, A. C., Lin, C. C., Chenot, J. F., . . . Koes, B. W. (2018). Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J, 27(11), 2791-2803. doi:10.1007/s00586-018-5673-2
Matthew has been working with our group since 2007 and is now the Team Leader of our Pain Management program at Bundoora. He has completed a PhD on individualised physiotherapy functional restoration management of multifactorial persistent low back pain.