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A statistically significant difference was found at the 5% level of significance between the experimental and control groups for pre-test transport/driving time.
The transport/driving time for the experimental group was significantly higher than that of the control group. No statistically significant differences were found between the pre-test of the experimental and control groups for any of the other measurements.
It can thus be concluded that, as far as the rest of the pre-test measurements are concerned, the two groups were very similar. The process of randomisation has thus ensured that the groups were as homogenous as possible at pre-test, ensuring an even spread of respondents across both groups. However, the difference in driving time could be explained by the fact that one respondent in the experimental group worked very far from home, while some of the respondents in the control group worked from home; thus increasing the difference between the two groups.
Time spent driving and the amount of hours worked per day were also recorded. This was done because it is believed that increased time spent sitting might contribute to chronic low back pain (McGill, 2002). When commuting to work, travel time becomes a factor, especially when travel time becomes prolonged, involving sitting for extended periods of time. Vibration also plays a role, especially when driving in a car and the whole body is exposed to vibration. This might also contribute to chronic low back pain. These two factors have been identified as causative factors (Andersson, 1997; Jansen et al., 2002; Laursen & Scibye, 2002; Leboeuf-Yde, 2004). When combined, they may theoretically cause more problems than when a patient is exposed to only one of these. However, the results from the study are not indicative in this regard because some respondents travel long distances to work while others work from home. Future research is required to provide answers on this topic.
Time spent working may also be regarded as a causative factor, especially when static postures are maintained for long periods of time as is the case with office workers and computer personnel. The mean score for the amount of hours worked in the experimental group was 10.19 hours per week and 9.07 hours per week for the control group. This is more than the average work day of 8 hours per day. However, the high level of importance placed on work and returning to work in cases of low back pain have been discussed in detail in chapter 2. Keeping patients away from work is not a sensible option. Work station modification and patient education have to play an important role in minimising strain placed on the patients with chronic low back pain to prevent absenteeism due to chronic low back pain.
There was no significant difference found between the experimental and control groups at post-test level for the Fear Avoidance Beliefs Questionnaire (FABQ) for any of the scales.
This result questions the effectiveness of the high-intensity back school used in the experimental group. It was expected to be more significantly effective than the lowintensity back school used in the control group. This again only partially confirms the hypothesis of the study because the experimental group was only slightly more effective. The high-intensity back school was certainly effective, as was shown by the results from pre-test to post-test. In the high-intensity back school approach the confrontational method to pain management was used, as suggested by Lethem et al.,(1983). However, an exercise intervention method uses this approach by default, as it challenges the fear of movement that patients could have (Vlaeyen & Linton, 2000).
The back school could reaffirm this new belief and confidence to move and to be active. This could be the reason why there was a small difference between the experimental and control groups’ back schools. The exercise programmes achieved most of the effect, as it challenged the patients to be active in a way that they did not think possible. To achieve a better result from the back school it might be more effective to identify patients who would benefit more from a cognitive intervention strategy, as proposed by Kääpä et al. (2006).
Frequency, Intensity and Duration
In terms of frequency, intensity and duration it is recommended that for frequency 2- 3 times per week is sufficient (Manniche et al., 1991; Oldridge & Stoll, 1997; Perkins & Zipple, 2003). Both the control and experimental groups performed their programmes twice per week in line with the recommendation. However, it is suggested that in early rehabilitation exercises should be performed daily with decreasing frequency as exercise tolerance increases. None of the patients in the study had ever participated in a low back rehabilitation programme up to the point of the intervention. A case could be made for rather performing the exercises daily, but it was decided to keep to two sessions per week to ensure supervision. Patients were not able to attend every day and the decision to supervise was decided to be more important.
The intensity of the exercise programmes, specifically for those with chronic low back pain, is more difficult to determine, as clear instructions are difficult to obtain. Available instructions usually suggest that the exercise prescribed should be more intense than that normally prescribed for back patients (Perkins & Zipple, 2003). The reason for this could be the necessity to increase functional ability, as those with chronic low back pain tend to become more disabled with time (Bergquist-Ullman & Larsson, 1977). One set of instructions, described as the Delorme method for intensity selection, suggests selecting resistance that allows 20-30 repetitions with proper neuromuscular control in a pain-free or minimal painful range of motion (Perkins & Zipple, 2003). Initially this will increase endurance and control of movement. As the person progresses, resistance should be increased while the number of repetitions decreased to 8-12, which is comparable with ACSM strength training guidelines (ACSM, 2000).
Self-selected intensity or exercise to pain tolerance often leads to inadequate exercise levels. Although pain might not improve for several months in many patients, an intensive exercise programme may result in greater functional and psychological benefits than a less aggressive approach (Perkins & Zipple, 2003). Others also suggest a quota approach, in which exercise intensity is prescribed to prevent under-exercising (Lindstrom et al., 1992; Linton, 1994; Rainville et al., 1997). This lends support for the use of a more aggressive exercise programme as used in the present study to focus on more issues relating to chronic low back pain than only subjective pain levels. Also, the present study attempted to use the Borg RPE scale to measure the intensity of the experimental group. The results show slight progressing in most exercises throughout the three training programmes. It shows sufficient exercise intensities to promote a training effect, but was not too strenuous at any stage that the danger of injury existed.
However, the present study failed to measure the control group by means of the RPE scale, which will place a limitation on the results of the experimental group because the two groups cannot be compared on this variable. Future studies should further investigate the use of this scale in patients with chronic low back pain and to determine whether this is a viable scale to use in rehabilitation for this population group.
CHAPTER 1: THE PROBLEM
1.1 Introduction
1.2 Research Questions
1.3 Research Hypothesis
1.4 Goals of the Study
1.5 Objectives of the Study
1.6 Research Design
1.7 Research Procedure and Strategy
1.8 Definition of Key Concepts
CHAPTER 2: LITERATURE SURVEY
2.1 Pain and its Physiology
2.2 The Problem of Low Back Pain
2.3 Low Back Anatomy
2.4 Recommended Treatment Modalities for Low Back Pain
2.5 Ergonomics: The Key to Protecting the Spine
2.6 Research Problem
CHAPTER 3: METHODOLOGY
3.1 Introduction
3.2 Participants
3.3 Methods and Materials
CHAPTER 4: RESULTS AND DISCUSSION
4.1 Background and Objectives
4.2 Research Design
4.3 Methodology
4.4 Statistical Analysis
4.5 Results
4.6 Case Studies
CHAPTER 5: SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1 Introduction
5.2 Summary of Results
5.3 Conclusion
5.4 Recommendations
5.5 Future Research
BIBLIOGRAPHY
