Archives of Physical Medicine and Rehabilitation
Volume 88, Issue 10 , Pages 1229-1235, October 2007

Comparison of a Functional Restoration Program With Active Individual Physical Therapy for Patients With Chronic Low Back Pain: A Randomized Controlled Trial

  • Ghislaine Roche, MD

      Affiliations

    • Laboratoire d’Ergonomie, Epidémiologie et Santé au Travail, Université d’Angers, Angers, France
    • Departments of Physical Medicine and Rehabilitation, Université d’Angers, Angers, France
    • ,
  • Anne Ponthieux, PhD

      Affiliations

    • Centre de Recherche Clinique, Centre Hospitalier Universitaire d’Angers, Angers, France
    • ,
  • Elsa Parot-Shinkel, MD

      Affiliations

    • Public Health, Université d’Angers, Angers, France
    • ,
  • Nathalie Jousset, MD

      Affiliations

    • Public Health, Université d’Angers, Angers, France
    • ,
  • Luc Bontoux, MD

      Affiliations

    • Departments of Physical Medicine and Rehabilitation, Université d’Angers, Angers, France
    • ,
  • Valérie Dubus, MD

      Affiliations

    • Departments of Physical Medicine and Rehabilitation, Université d’Angers, Angers, France
    • ,
  • Dominique Penneau-Fontbonne, MD, PhD

      Affiliations

    • Laboratoire d’Ergonomie, Epidémiologie et Santé au Travail, Université d’Angers, Angers, France
    • Occupational Health Department, Université d’Angers, Angers, France
    • ,
  • Yves Roquelaure, MD, PhD

      Affiliations

    • Laboratoire d’Ergonomie, Epidémiologie et Santé au Travail, Université d’Angers, Angers, France
    • Occupational Health Department, Université d’Angers, Angers, France
    • ,
  • Erick Legrand, MD, PhD

      Affiliations

    • Rheumatology, Université d’Angers, Angers, France
    • INSERM EMI 0335, Université d’Angers, Angers, France
    • ,
  • Denis Colin, MD, PhD

      Affiliations

    • Centre de Rééducation de l’Arche, Saint-Saturnin, France.
    • ,
  • Isabelle Richard, MD, PhD

      Affiliations

    • Laboratoire d’Ergonomie, Epidémiologie et Santé au Travail, Université d’Angers, Angers, France
    • Departments of Physical Medicine and Rehabilitation, Université d’Angers, Angers, France
    • Corresponding Author InformationReprint requests to Isabelle Richard, MD, PhD, Département de Médecine Physique et Réadaptation Adulte, CHU-CRRRF, 3 rue des Capucins, BP 40329, 49103 Angers Cedex 02, France
    • ,
  • Serge Fanello, MD, PhD

      Affiliations

    • Laboratoire d’Ergonomie, Epidémiologie et Santé au Travail, Université d’Angers, Angers, France
    • Public Health, Université d’Angers, Angers, France

Article Outline

Abstract 

Roche G, Ponthieux A, Parot-Shinkel E, Jousset N, Bontoux L, Dubus V, Penneau-Fontbonne D, Roquelaure Y, Legrand E, Colin D, Richard I, Fanello S. Comparison of a functional restoration program with active individual physical therapy for patients with chronic low back pain: a randomized controlled trial.

Objective

To compare the short-term outcomes of active individual therapy (AIT) with those of a functional restoration program (FRP).

Design

Prospective randomized controlled study.

Setting

Two rehabilitation centers and private ambulatory physiotherapy facilities.

Participants

One hundred thirty-two adults with chronic low back pain. Fifty-one percent of patients on sick leave or out of work (mean duration, 180d in the 2y before treatment).

Interventions

For 5 weeks, FRP (at 25h/wk) or AIT (at 3h/wk).

Main Outcome Measures

Trunk flexibility, back flexor, and extensor endurance (Ito and Sorensen tests), general endurance, pain intensity, Dallas Pain Questionnaire (DPQ) scores, daily activities, anxiety depression, social interest, and work and leisure activities, and self-reported improvement (work ability, resumption of sport and leisure activities).

Results

All outcome measures improved after treatment except endurance in AIT. There was no between-group difference for pain intensity or DPQ daily activities or work and leisure activities scores. Better results were observed in FRP for all other outcome measures. There was a significant effect of treatment and the initial value for the gain of the Sorensen score with a treatment or initial value interaction; a significant effect of treatment and initial value on the gains of Ito, endurance, and DPQ social interest and anxiety depression scores, with no treatment or initial value interaction; and a significant effect of initial value but not treatment for the gains of DPQ daily activities and work and leisure activities scores.

Conclusions

Low-cost ambulatory AIT is effective. The main advantage of FRP is improved endurance. We speculate that this may be linked to better self-reported work ability and more frequent resumption of sports and leisure activities.

Key Words: Low back pain, Physical therapy modalities, Rehabilitation, Randomized clinical trial

 

CHRONIC LOW BACK PAIN (CLBP) is a major public health issue, representing high costs for the health care system. A recent study showed the average overall cost per patient in France to be 15,000 euros, the largest part being indirect costs because of sick-leave payments.1 In the last 30 years, the social and financial burdens of CLBP have led to the establishment of various multidisciplinary rehabilitation programs. “Back schools” have been developed since the 1970s, offering a combination of patient information and postural training.2, 3, 4 Patients participated in information sessions focused on basic anatomy and physiology and were trained in various lifting techniques. In the late 1980s, the concept of physical deconditioning5 was introduced, which led to the development of functional restoration programs.6, 7, 8, 9, 10, 11, 12, 13 Deconditioning, which denotes a physical and psychologic state induced by inactivity because of low back pain (LBP), is characterized by a loss of spinal mobility, reduction of muscle strength and cardiovascular fitness, frequent anxiety and depression, social isolation, and absence from work. Multidisciplinary functional restoration programs have included intensive training to increase flexibility, force, and endurance as well as psychologic counseling and occupational therapy. In the mid-1990s, attention shifted toward the interactions between the LBP patient and the environment, leading to the development of intervention programs involving the patient’s employer and medical care providers. Such programs have usually included ergonomic intervention and have often been embedded in public health care policies.14, 15, 16, 17, 18 Although the design of LBP programs has varied over time and across different countries, there is an international consensus regarding the value of active exercise and the idea that the programs should also include formal and informal activities aimed at improving coping strategies (eg, psychologic counseling, group effect, interaction with the work environment).

Most studies6, 8, 12, 13, 19, 20 consider the main outcome to be return to work and/or the number of days of sick leave taken. This is relevant because sick leave accounts for the main costs. Using this outcome measure, many studies6, 8, 21 have shown the effectiveness of LBP programs with a reduction in days of sick leave occurring in the year after the program. Thus, the effectiveness of specific interventions has been quite clearly established in comparison to nonintervention although long-term results are often not studied. These programs have now been implemented in most developed countries. The next step has been the comparison of different programs to improve both the outcome and cost-effectiveness of treatments. Greater cost-effectiveness allows the treatment of a greater number of LBP patients with a given quantity of resources. Various studies have, therefore, compared intensive rehabilitation-based programs, which are mainly derived from functional restoration programs, with less intensive ambulatory-based programs, ranging from programs including 2 or 3 supervised sessions per week12, 22, 23, 24, 25 to ones that are exclusively home based.26, 27 In a previously reported trial,28 we compared the number of days of sick leave in the year after participation in an intensive program with those after active ambulatory therapy. This study showed that there was a significant reduction in sick leave after ambulatory therapy but a significantly greater reduction after the intensive program, leading to the conclusion that “more intensive” and “more expensive” is better on an individual level, but this is not necessarily feasible for application to a large population. Similar conclusions have also been reached by others.12, 13 The results thus far available have not made possible the development of criteria that could help determine which treatment should be applied to which patient to maximize the effectiveness of available resources. They also do not reveal which component of each treatment is essential. The optimal amount of physical reconditioning, psychologic counseling, and ergonomic intervention and the specific effects of individual versus group therapy all remain to be established. It, therefore, appears necessary to open the black box of multidisciplinary programs, focusing on selected elementary outcomes such as trunk extensor strength, endurance, and psychologic status, and to try to understand which components of treatment influence which outcomes and how the latter are related to the pretreatment status of the patient. Obtaining such data is a necessary preliminary step before directing patients to an array of programs, ranging from less intensive ambulatory-based programs to specialized hospital-based ones.

Therefore, the aim of the present study is to compare the gains in terms of selected physical and psychologic outcomes obtained from 2 LBP programs that differ in the intensity of the physical training and the psychologic counseling procedures used. The cross relations between the treatment effect and the initial status of the patient are also analyzed.

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Methods 

Population 

All patients with CLBP aged 18 to 50 years referred consecutively to a multidisciplinary LBP clinic in a level 1 hospital were eligible for inclusion. A physical medicine and rehabilitation specialist, an occupational medicine specialist, a psychiatrist, and an ergonomist evaluated each patient independently. Each patient underwent a standardized medical examination.

The inclusion criteria were patients aged 18 to 50 years (referred to the multidisciplinary clinic between January 2000 and April 2003) with LBP for at least 3 months and patients on sick leave or at risk of work disability and not in temporary employment. The exclusion criteria were patients with malignant, traumatic, infectious, or inflammatory LBP; patients with acute LBP or sciatica, spondylolisthesis, or cardiac or respiratory insufficiency (diagnosed after exercise stress test on bicycle ergometer); patients with articular or neurologic impairment incompatible with a physical exercise program; patients with psychiatric disorders precluding participation in group therapy; and patients receiving disability pensions or refusing to participate in the study.

This study was approved by the local ethics committee, and written informed consent was obtained from each patient. After inclusion in the study, the patients were randomized into 2 groups and allocated to the active individual therapy program (AIT) or the functional restoration program (FRP). Block randomization was undertaken with an 8-element permutation table established by an independent methodologist.

Treatment 

The treatment content of each program was different. The FRP lasted 5 weeks and involved 6 hours of treatment a day, 5 days a week in groups of 6 to 8 patients. It was undertaken identically in 2 rehabilitation centers. The AIT lasted 5 weeks and included individual rehabilitation with a private practice physiotherapist for 1 hour 3 times a week and individual exercises to be performed at home for 50 minutes twice a week.

Functional restoration program 

The group performed exercises supervised by a physiotherapist who adjusted the exercise intensity to each participant every week. During the first week, patients learned muscular warm-up and stretching techniques, improved their flexibility, and performed cardiorespiratory exercises. During the second week, patients began muscular-strengthening exercises. During the third week, muscular strengthening increased with endurance exercises. Patients performed weightlifting as well as proprioception and coordination exercises. In the fourth and fifth weeks, the intensity of strengthening exercises increased progressively. The endurance training was adapted to each patient’s heart rate and to the exercise stress test performed before the program. Patients performed work simulations during occupational therapy sessions.

Strengthening exercises were performed exclusively with isotonic techniques. Proprioception was developed with static and dynamic destabilization exercises. Walking, running, and cycling developed cardiorespiratory endurance.

Each week patients attended a clinic with the specialist in physical medicine and rehabilitation who was the medical supervisor of the program. They were referred to the psychologist at least once in the first week and for further treatment if requested. Dietary advice was given. The schedule of interventions was standardized for all patients (appendix 1).

Active individual therapy 

Each individual session lasted 1 hour and included only active exercises supervised directly by the physiotherapist. All physiotherapists participated in an information session and agreed to apply the program as described. During the first 2 weeks, the program included flexibility training and pain management, stretching, and proprioception exercises. Patients continued these exercises during the third and fourth weeks and started muscular strengthening. The last week focused on functional exercises and endurance training. The program included 50 minutes of individual home exercises 2 days a week (these could include stretching, jogging, and swimming). This part of the program was agreed on by the patient and physiotherapist and depended on the facilities available. It was not standardized. All exercises were isotonic, and no specific equipment was required or provided. At the beginning of the program, patients signed an agreement to follow the prescribed exercises. Patients had to record the duration, type, and number of exercises performed at home.

In both groups, patients were off work during the 5 weeks of treatment. At the beginning (t0) and the end of the treatment (t5), they were assessed in the rehabilitation center by physiatrists, and the questionnaires were completed. The physical evaluations were performed by physiotherapists. The cross-evaluation was performed by private-practice physiotherapists for the FRP patients and by physiotherapists of the rehabilitation centers for the AIT patients. One training session was provided to reduce evaluator-dependent bias.

Evaluation Criteria 

Trunk flexibility was assessed by the fingertip-to-floor (FTF) distance, measured in centimeters.29 Trunk muscle endurance was assessed by the Sorensen test (time of isometric contraction of extensor muscles measured in seconds)30 and the Ito test (time of isometric contraction of flexors muscles also measured in seconds).31 General endurance (in kilojoules) was measured during a cyclo-ergometer test, limited to 85% of maximum cardiac frequency measured during a previous stress test.

The severity of LBP was scored on a 10-cm visual analog scale (VAS), where 0 indicates no pain and 10 the worst possible pain.32, 33 The Dallas Pain Questionnaire (DPQ)34, 35 was used to assess the impact of pain on quality of life (QOL) and included 4 items scored from 0% to 100%: daily activities, work and leisure activities, anxiety and depression, and social interest.

All items were evaluated at the beginning (t0) and at the end (t5) of treatment. Patients were also asked at the end of treatment whether they believed their physical fitness had improved, whether they had resumed sports activities, and whether they felt able to work.

Statistical Analysis 

The statistical analysis was performed with SPSS software.a The t and chi-square tests were performed to test differences between the AIT and FRP groups in terms of the patients’ initial characteristics. The evolution of FTF distance, Sorensen score, Ito score, endurance, VAS, and DPQ scores between t0 and t5 were examined by using a paired t test and the McNemar test.

Changes in Ito, Sorensen, endurance, and the 4 DPQ scores between t0 and t5 were assessed by using analysis of covariance (ANCOVA), with a main-effects model that included their respective values at t0 (t0 Sorensen) as a covariate and treatment effects (AIT or FRP).

The level of significance was defined as .05.

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Results 

One hundred thirty-two patients (86 men, 46 women) were included. The mean age was 39.8 years (range, 24–50y). Sixty-eight patients were randomized in the FRP group and 64 in the AIT group.

Pretreatment Characteristics 

There was no significant difference between the 2 groups (table 1) with regard to sex, age, history of depression, and LBP associated with work accidents. More subjects had undergone surgery in the FRP group.

Table 1. Patients’ Initial Characteristics (t0) (N=132)
CharacteristicsAIT (n=64)FRP (n=68)P⁎
Age (y)38.7±6.140.8±7.4NS
Sex (% men)62.567.65NS
Body mass index (kg/m2)26.2±4.825.9±4.0NS
Previous depression (%)17.223.5NS
LBP associated with work accident or occupational disease (%)46.941.2NS
History of spinal surgery (%)18.833.8.050
FTF distance (cm)13.8±12.712.6±9.3NS
Sorensen test (s)84.8±53.597.7±50.7NS
Ito test (s)65.6±47.878.3±50.3NS
Endurance (kJ)57.5±34.262.9±37.3NS
VAS (cm)4.5±2.14.7±2.1NS
DPQ daily activities (%)51.051.8NS
DPQ work and leisure (%)58.051.9NS
DPQ anxiety and depression (%)30.936.9NS
DPQ social comportment (%)27.430.7NS
Work before treatment NS
Full time (%)37.544.1
Part time (%)11.013.2
On sick leave (%)51.642.7

NOTE. Values are mean ± standard deviation or percent.

Abbreviation: NS, not significant.

⁎Comparison between AIT and FRP using the t test or chi-square test.

There was no significant difference across groups regarding days of sick leave in the 2 years before treatment (180±135.1d in AIT vs 185±149.8d in FRP, P=.847). Fifty-one percent of the patients were on sick leave before treatment.

There was no significant difference between the groups in terms of body mass index, physical measures, and QOL scores.

Evolution After Treatment 

Some patients did not perform all the tests at t5; 1 patient did not perform the endurance test because of a right tibial fracture. Six patients could not perform the endurance test because of breakdown of the bicycle ergometer. Patients’ flowcharts throughout the study are summarized in figure 1.

Results in the AIT group were higher at t5 than at t0 for each physical test except the endurance test (P=.360). Pain severity on VAS and every score of the DPQ except for the social interest score (P=.068) were significantly lower at t5 than at t0. In the FRP group, measures were significantly higher at t5 than at t0 for every physical measure and lower for every score of the DPQ. The differences between t0 and t5 were significantly greater in the FRP group than in the AIT group for physical tests and the DPQ anxiety and depression and social interest scores (table 2). There was no significant difference between the 2 treatment groups for the other scores of the DPQ.

Table 2. Evolution Between t0 and t5 (N=132)
TestAITFRPComparison AIT/FRP P†
Difference t5−t0P⁎Difference t5−t0P⁎
FTF distance (cm)−11.9∥−16.3∥‡
Sorensen test (s)61.2∥100.7∥∥
Ito test (s)71.2∥121.3∥∥
Endurance (kJ)4.2NS32.5∥∥
VAS (cm)−1.5∥−1.9∥NS
DPQ daily activities (%)−17.2∥−21.5∥NS
DPQ work and leisure (%)−19.8∥−22.0∥NS
DPQ anxiety and depression (%)−7.4§−17.6∥§
DPQ social interaction (%)−4.1NS−13.6∥§

⁎Comparison between t0 and t5 using paired t test or McNemar test.

†Comparison of difference t5−t0 between AIT and FRP using the t test or chi-square test.

‡P<.05.

§P<.01.

∥P<.001.

The majority of patients considered their physical fitness to be improved in both groups. More patients in the FRP group were taking part in sports or leisure activities (P<.001) or felt that they were able to return to work (P=.003) at the end of treatment (table 3).

Table 3. Qualitative Measures at t5 (n=132)
MeasuresAITFRPP⁎
Increased physical fitness (%)90.697.0NS
Resumption of sports and leisure (%)65.694.1‡
Ability to return to work (%)78.195.5†
Return to work (%)85.786.8NS
Full time (%)74.574.6NS
Same work station (%)75.580.0NS

⁎Comparison between AIT and FRP using the chi-square test.

†P<.01.

‡P<.001.

Interaction Among Improvement, Initial Status, and Treatment 

The change in Sorensen test score between t0 and t5 correlated significantly with the t0 Sorensen score (ANCOVA, P<.001) and treatment (ANCOVA, P<.001). The interaction term between the t0 Sorensen score and treatment was also significant (ANCOVA, P=.001). There was greater improvement in Sorensen score for patients with lower t0 Sorensen scores and in the FRP group (fig 2A).

  • View full-size image.
  • Fig 2. 

    Effect of initial value and treatment on changes in (A) Sorensen, (B) Ito, and (C) DPQ scores. Linear regressions for AIT (unbroken line and •) and FRP (dotted line and ○).

Changes between t0 and t5 for Ito and endurance measures and for the DPQ social interest and anxiety and depression scores correlated significantly with their respective values at t0 (ANCOVA, P=.004, P=.017, P<.001, P<.001, respectively) and with treatment (ANCOVA, P<.001, P<.001, P=.003, P=.014, respectively), but there were no significant interaction terms between their respective values at t0 and treatment. There was greater improvement in outcomes for patients with lower scores at t0 and with FRP (fig 2B).

Changes between t0 and t5 for the DPQ daily activities and work and leisure activities scores correlated significantly with their respective values at t0 (ANCOVA, P<.001, P<.001) but not with treatment. There was greater improvement in outcomes for patients with lower scores at t0 (fig 2C).

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Discussion 

The study was a randomized prospective clinical trial with 2 parallel groups and compared an intensive functional restoration program with specific active individual rehabilitation with physiotherapists in private practice by using a protocol in accordance with the international guidelines36, 37, 38 for active therapy in CLBP. The samples were comparable before treatment in terms of age, sex, socioeconomic and physical characteristics, and QOL indices.

Pain relief was not the main objective in either program. The FRP and the AIT protocols both required the patients to “work through pain”; the main objective was to resume normal activity and return to work. Despite the considerable differences in the intensity of the programs, there was no difference in pain level between the 2 groups at t5. Pain intensity decreased in both groups. This result is comparable with previous results on FRP6, 9, 12 and on physical exercise22, 39, 40 that have shown that exercise reduces pain intensity. No subject elected to discontinue participating in the program.

The direct effectiveness of the treatments was assessed by clinical data, physical measures, and the functional and psychosocial consequences of LBP. A comparison of the results between t0 and t5 provided an evaluation of the patients’ improvement with each protocol. The between-group comparison of gains indicated whether one method was more effective than the other. Analysis of the interaction between initial values and treatments may help refer patients for programs.

Physical measures were significantly improved in both treatment groups except for endurance in the AIT group. The improvement was significantly greater in the FRP group for all physical measures except for pain level. The improvements in Sorensen, Ito, and endurance scores were influenced by the levels of these scores at t0 and the treatment; patients with lower scores at t0 showed greater improvement than patients with higher scores, and there was greater improvement with FRP than with AIT. These results suggest that patients with severe physical-deconditioning syndrome should be referred in programs including supervised endurance training.

The strength of trunk muscles has been considered to be a key item of physical deconditioning,5 and muscular strengthening is often the main part of LBP programs.6, 38, 41, 42 Several techniques and training protocols have been described. Many programs include isokinetic training6, 8 or isoinertial techniques9, 41, 43 and the use of specific training machines. The main advantages of these techniques are to provide continuous feedback to patients on their performance level and to quantify their progress toward treatment goals. These elements play a role in patients’ tolerance of the exercises and may improve their motivation during treatment. The trunk muscle training in our AIT program was performed exclusively by isotonic techniques; private practice physiotherapists do not usually have isokinetic training machines because they are very expensive. A recent study44 comparing training on isokinetic devices with standard physiotherapy has shown similar results, and there is currently no evidence of the superiority of any given technique.36, 42

The active individual physiotherapy did increase the endurance of isometric back extension, but this gain was significantly lower than with FRP, especially for very weak patients. The decreased endurance of back extensors is thought to be a risk factor for CLBP.30 If this factor is crucial in the overall result, patients with weak trunk extensors at inclusion could be referred to an intensive program. For patients with higher initial trunk extensor endurance, the gain is lower, and the treatment effect favors the AIT program. This result could indicate that patients with higher scores do not require intensive physical training and can be referred to ambulatory-based programs. For these patients, greater attention to their psychologic status and work environment might be more relevant than intensive physical training.

Most LBP programs include flexibility exercises.6, 8, 9, 36 In our study, FTF distance was significantly reduced by both treatments. The improvement in flexibility was significantly greater in the FRP, but, although statistically significant, the difference was not of clinical relevance. The aim of such programs is a return to average flexibility, and this result was achieved by performing stretching exercises 3 times a week, with a mean FTF in the AIT program of 1.9cm.

General endurance was improved only in the FRP group. One of the important differences between the 2 treatments was the direct supervision of aerobic exercises (jogging, badminton, swimming) in the FRP program, whereas the patients in the AIT program were only given advice that they should perform such exercise twice a week. This may be related to the higher proportion of patients in the FRP group having resumed leisure and sports activities. It may also have led to a difference in the evolution of the 2 groups, patients with less endurance possibly being more likely to discontinue physical activities after completing the program. This warrants further study, including long-term follow-up of endurance and performance of physical activities. General endurance, combined with trunk muscle endurance, could be used as a criterion for deciding between less and more intensive programs. Peer groups, such as those developed by patients with cardiovascular disease, could also lead to modified ambulatory programs, including supervised group aerobic activities.

Psychosocial status is a major component of LBP-related disability.45, 46 Psychosocial risk factors can include fear (of pain, of work-related activities, of movement), distress (anxiety or depression), attitudes and beliefs, and relationship factors (eg, conflict or lack of support).47 The reduction of subjective feelings of disability21 and of general or emotional distress48 has been shown to be a key determinant in returning to work. DPQ scores improved with both programs in our study, despite the absence of any specific psychologic treatment in the AIT group. The treatment effect, regardless of the content of the treatment, is probably of major importance for these patients. The improvement in the AIT group could also be explained by the informal support provided by the physiotherapist through his relationship with the patient. Physical exercise has also been shown to have a direct effect on depression.49

The improvement in the DPQ daily activities and work and leisure activities scores was significantly higher in the FRP. This was probably related to the higher self-reported ability to resume work and leisure activities in this group. This could be a further argument for the referral of patients with low DPQ scores to intensive programs and/or for the introduction of peer groups in ambulatory programs.

Attitudes and fears toward physical and work activities are also of known importance in the resumption of both work and leisure activities.50 They can be evaluated by the Fear-Avoidance Beliefs Questionnaire,51 and further studies are required to evaluate the treatment effect of this parameter.

These conclusions could help shape policies for application to larger populations. Low-cost ambulatory programs are probably sufficient for a high proportion of patients. These ambulatory programs could probably be improved by the participation of patients in peer groups providing psychologic support and motivation for aerobic training at a much lower cost than inclusion in hospital-based rehabilitation programs.

Study Limitations 

Limitations of this study include the following. Compliance with both programs should have been assessed.52 The AIT home-exercise program was easy to follow. It required no specific equipment and was of a duration compatible with other daily activities (50min). It was tailored to each patient and was agreed on by the physiotherapist who ensured that the patient was able to perform the exercises correctly. We tried to increase motivation and involvement in the program by asking the patient to sign a written agreement and report the actual duration and type of exercises performed.

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Conclusions 

Low-cost ambulatory AIT is effective. The main advantage of FRP is improved endurance. We speculate that this may be linked to better self-reported work ability and more frequent resumption of sports and leisure activities.

Suppliers

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Appendix 1. Schedule of Interventions in the FRP 

Group interventions (6 to 8 patients):

9:00 am to 10:00 am: Warm-up, stretching, and proprioception exercises: walking, running, stretching of trunk and limbs muscles, balance exercises (for dynamic destabilization exercises), and various games.

10:15 am to 11:15 am: Strengthening exercises (isotonic training of all major muscular groups).

11:30 am to 12:30 pm: Aerobic activities (jogging, ball games).

Lunch.

1:30 pm to 2:00 pm: Warm-up, stretching, and proprioception exercises.

2:00 pm to 3:15 pm: Occupational therapy (training in flexibility, endurance and coordination exercises, weight lifting, and work simulation).

3:30 pm to 4:15 pm: Global strengthening exercises and endurance training (jogging, stepping, and cycling exercises).

4:30 pm to 5:00 pm: Balneotherapy (for muscular recovery and proprioception exercises).

Individual interventions: meetings with the physiatrist, the psychologist, and the dietician.

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  • a Version 12.0; SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

 Supported by the Union Régionale des Caisses d’Assurance Maladie des Pays de Loire.

 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

PII: S0003-9993(07)01286-5

doi:10.1016/j.apmr.2007.07.014

Archives of Physical Medicine and Rehabilitation
Volume 88, Issue 10 , Pages 1229-1235, October 2007

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