Non-pharmacological Home Therapies for Subacute Low Back Pain in Active Duty Military Personnel: A Randomized Controlled Trial

Abstract

Introduction Low back pain (LBP) is a major cause of visits to ambulatory care, missed duty time, and disability discharge. The subacute phase of LBP presents an opportune time to prevent chronicity and lessen recurrence. The goal of this randomized controlled trial (RCT) was to determine the relative effectiveness of neuromuscular electrical stimulation (NMES) training and a progressive exercise program (PEP) on improving physical performance, pain, and torso strength in U.S. service members with subacute LBP, compared to standard primary care management (PCM) alone. Methods This is an Institutional Review Board–approved protocol for an RCT conducted with active duty military personnel (n = 128) at Fort Campbell, Kentucky, between April 2018 and March 2020. Participants were randomized to receive NMES (n = 43), PEP (n = 42), or PCM (n = 43) for 9 weeks. Outcome measures of physical performance (sit-ups, push-ups, walking, and torso endurance), torso muscle strength (flexion and extension), and pain were assessed at baseline and after 3, 6, and 9 weeks. Analysis was intent-to-treat using linear mixed effects models. A sensitivity analysis was performed to address the protocol deviations that occurred in response to coronavirus disease 2019 pandemic, which required rescheduling 17 in-person study visits to home assessments at 9-week testing. Results Evidence was found for group differences in physical performance for sit-ups and push-ups, with NMES showing greater improvement than PCM. The two groups showed similar improvements in torso muscle strength, although the NMES groups may show better improvement during early treatment. No group differences in pain levels were observed during the intervention, and all groups improved during the course of the study period. The amount of NMES muscle stimulation was directly related to the level of improvement, which was not the case for the hours reported for PEP exercise. Conclusion In an active duty population with subacute LBP, integrating NMES strength training into the rehabilitation therapy may offer a modest benefit for increasing sit-ups and push-ups and improving torso strength.

Efficacy of Conservative Interventions for Musculoskeletal Conditions on Pain and Disability in Active Serving Military Personnel—A Systematic Review

“…3A ). 37 No improvement in LBP intensity scores were reported for electrotherapy modalities 38 , 45 or adjunctive osteopathic manipulation 31 (SMD: −0.50; 95% CI: −1.00 to 0.00) ( Fig. 2A ) when compared to usual care alone.…”

“…Low back pain was the most frequently investigated MSK condition. 29 , 31 , 32 , 34–40 , 42 , 45 , 46 Three studies addressed interventions for acute LBP. 31 , 32 , 34 Two studies assessed knee pain, 44 , 47 and one study included both knee pain and LBP.…”

“…The interventions in the experimental groups for the management of MSK pain included early physiotherapy intervention, 39 multidisciplinary pain programs (physiotherapy, occupational therapy, and psychology), 30 , 33 adjunct manipulative treatment, 31 , 34 , 46 exercise therapies, 32 , 35 , 36 , 40–43 , 45 , 47 a dietary supplement of combined glucosamine, chondroitin sulfate, and manganese ascorbate, 37 and electrotherapy modalities. 38 , 44 , 45 , 47 The interventions in the control groups consisted of usual care, 29 , 31 , 33 , 34 , 38 , 39 , 41 , 43 , 45 , 47 wait-list, 30 , 35 , 46 exercise, 40 , 42 , 44 physiotherapy, 36 and ice application. 32 …”

“…Rather, pain medication (e.g., NSAIDs and acetaminophen) were reported as a co-intervention in some studies. 31 , 34 , 37–40 , 45 , 46 Recent literature on strategies for the management of MSK pain implemented by active serving personnel report that over-the-counter and opioid medications are frequently used. 12 , 14 , 57 Thus, the lack of representation of pharmacological management strategies in this review may not be reflective of current practice.…”

“…Another source of bias common to the included studies was being statistically underpowered. More than half 29–31 , 34–36 , 38–41 , 44 , 45 of the included studies did not meet the a priori power calculations or desired sample size for pain-related outcomes, thus reducing the robustness of the findings. Many of the studies cited limitations to study recruitment in active serving populations.…”