Effects of Physical Activities on Pain and Functional Recovery in Low Back Pain

下背痛（LBP）是全球残疾的头号原因，也是退伍军人的主要原因。LBP有一个 大多数人的复发过程，包括患者必须定期发生的新事件， 管理。因此，新的LBP事件是干预措施有望实现的关键节点。 优化功能恢复，促进重返工作岗位（RTW），并避免下游的级联 阿片类药物的使用，心理健康问题，甚至自杀和死亡的风险等后果。 在新的LBP发作期间保持活跃的一般建议是临床实践指南的关键部分。 然而，现有的准则没有提供关于活动类型的具体建议（例如，提升， 弯曲等）应该参与或避免的（“哪一个？”）或此类活动的持续时间/强度 他们应该如何执行（“如何？”）。因此，该指南没有解决患者的主要问题， LBP，即某些活动可能对疼痛加剧或“耀斑”产生短期影响，或导致 对疼痛或功能的持续有害影响。健康、良性和有害之间的区别 活动对临床医生也很重要，他们经常被要求填写“工作限制表”， 在RTW过程中。在新的LBP发作后，一套理想的工作限制将只限制这些活动 可能导致疼痛发作（短期影响）或长期整体功能恢复不良 （整体效果）。然而，没有关于短期与总体的经验数据 在新的LBP发作期间，特定活动的影响，以此指导工作限制。 相反，在标准实践中，临床医生参与或避免特定活动的建议依赖于他们的 个人实践风格，如果过度限制，可能会限制功能恢复。该研究将使用一个 一种区分活动的短期影响与此类活动的总体影响的新方法， 在队列研究中进行纵向病例交叉研究。该设计考虑到 通过使用每个病例作为自己的对照，类似于交叉， 实验，利用现代移动的健康和活动记录技术。 目的1：评估特定体力活动对疼痛发作的短期影响（约24小时）， 退伍军人LBP将进行一项纵向病例交叉研究，以确定触发 550名工作年龄（18-65岁）的退伍军人在VA初级保健中因新的LBP发作而发作。的 主要结局是以疼痛和功能影响为特征的经验证的发作定义。分析将使用 生物心理社会框架解释潜在的混杂因素和调节因素，如疼痛特征， 与工作有关的因素，灾难化，害怕运动，抑郁症，创伤后应激反应和阿片类药物的使用。 目的2：评估特定体力活动对退伍军人LBP的整体影响。一项队列 目标1研究样本的研究方法将检查特定频率之间的关联 在随访的前8周内的活动，以及由 12个月随访时的罗兰-莫里斯残疾问卷（主要结局）。分析还将使用 正如目标1所做的那样，生物心理社会框架考虑了广泛的其他因素。二次 结果包括平均疼痛强度，工作效率损失，生活质量和12个月时的阿片类药物使用。 这些研究目标将产生第一个基于证据的短期和整体风险估计， LBP期间的活动这些数据将（1）支持退伍军人与LBP导航复杂的过程， 恢复，（2）协助VA临床医生提供工作限制，（3）告知未来的发展 对LBP的教育干预可以在未来的RCT中进行测试。因此，这项工作直接回应了 康复研究和发展服务呼吁对慢性疼痛进行基于活动的干预。

Low back pain (LBP) is the #1 cause of disability worldwide and a leading cause among Veterans. LBP has a recurrent course for most individuals, involving the periodic occurrence of new episodes that patients must manage. New LBP episodes therefore are critical juncture points where interventions hold promise for optimizing functional recovery, promoting return to work (RTW), and averting a cascade of downstream consequences such as opioid use, mental health problems, and even the risk of suicide and death. The general advice to remain active during a new LBP episode is a key part of clinical practice guidelines. However, existing guidelines provide no specific recommendations about the types of activity (e.g., lifting, bending, etc.) that should be engaged in or avoided (“Which?”) or the duration/intensity of such activities should they be performed (“How?”). The guidelines therefore do not address a major concern of patients with LBP, which is that certain activities may have short-term effects on pain exacerbations or “flares”, or cause sustained detrimental effects on pain or function. The distinctions between healthy, benign, and detrimental activities are also important to clinicians, who are often called upon to complete “work restriction forms” as part of the RTW process. An ideal set of work restrictions after a new LBP episode would limit only those activities that are likely to cause flares of pain (short-term effects) or poor overall functional recovery in the longer term (overall effects). However, there exist no empirically derived data concerning the short-term vs. overall effects of specific activities during a new episode of LBP, with which to guide work restrictions. Instead, in standard practice, clinicians’ recommendations to engage in or avoid specific activities rely on their personal practice style and may limit functional recovery if overly restrictive. The proposed research will use a novel approach to distinguish the short-term effects of activities from the overall effects of such activities, by conducting a longitudinal case-crossover study nested within a cohort study. This design accounts for measured and unmeasured confounds by using each case as his/her own control, analogous to a crossover experiment, capitalizing on modern mobile health and actigraphy technology. Aim 1: Estimate the short-term effects (24 hours) of specific physical activities on pain flares in Veterans with LBP. A longitudinal case-crossover study will be conducted to identify activities that trigger flares among 550 Veterans of working age (18-65 yrs) seen for a new LBP episode in VA primary care. The primary outcome is a validated flare definition characterized by pain and functional impact. Analyses will use a biopsychosocial framework accounting for potential confounders and moderators, such as pain characteristics, work-related factors, catastrophizing, fear of movement, depression, post-traumatic stress, and opioid use. Aim 2: Estimate the overall effects of specific physical activities among Veterans with LBP. A cohort study approach to the Aim 1 study sample will examine associations between the frequency of specific activities over the first 8 weeks of follow-up, and overall LBP-related functional recovery as defined by the Roland-Morris Disability Questionnaire at 12-month follow-up (primary outcome). Analyses will also use a biopsychosocial framework accounting for a broad range of other factors, as done for Aim 1. Secondary outcomes include average pain intensity, lost work productivity, quality of life, and opioid use at 12 months. These study aims will produce the first evidence-based estimates of the short-term and overall risks of activities during LBP. These data will (1) support Veterans with LBP in navigating the complex process of recovery, (2) assist VA clinicians in providing work restrictions, and (3) inform the development of a future educational intervention for LBP that can be tested in a future RCT. Thus, this work responds directly to the Rehabilitation Research and Development service’s call for activity-based interventions for chronic pain.