Efficacy of Therapeutic Aquatic Exercise vs Physical Therapy Modalities for Patients With Chronic Low Back Pain

Key Points Question Is therapeutic aquatic exercise as effective as physical therapy modalities in the management of adults with chronic low back pain? Findings In this randomized clinical trial of 113 individuals with chronic low back pain, therapeutic aquatic exercise had a greater influence on pain, function, quality of life, sleep quality, and mental state than physical therapy modalities after a 3-month intervention, and the effect was present up to the 12-month follow-up. The recommendation rate of therapeutic aquatic exercise was significantly higher than that of physical therapy modalities. Meaning The findings of this trial suggest that therapeutic aquatic exercise is an effective treatment for adults with chronic low back pain.

Drug therapy is one of the most commonly used treatments for CLBP, but side effects 23 due to medication are inevitable. 10,11 Considering that the condition of most patients 24 with CLBP improves naturally regardless of treatment, nonpharmacologic and 25 nonsurgical methods should be the first-line choice. 9,12 Clinical applications in 26 patients with CLBP, physical therapy modalities (PTMs), such as transcutaneous 27 electrical nerve stimulation (TENS) and far-infrared (FIR) irradiation therapy, is 28 regard as a relatively safe, convenience and non-invasive option. 13,14 Nowadays,29 exercise therapy is widely recommended as a valid way for pain relief and functional 30 TAE group 139 The temperature will be customized at 30 °C of water and 27.5 °C of environment to 140 elicit the same heart response both in water and in air. The entire intervention will be 141 completed in a swimming pool with a dimension of 20 m × 6 m and a depth of 142 1.3-1.5 m. To ensure that all of the participants will be submerged at their xiphoid 143 bone level, some aquatic steps will be placed underwater as auxiliary forces. 144 The TAE protocol will be designed by the researcher in accordance with available 145 scientific evidence. During the exercise, the participants will receive verbal, tactile, 146 and visual information to correct their movements and ensure that the lumbar spine 147 remains in a neutral position while standing. Thus, excessive loading on the spine will 148 be avoided, and trunk muscles will be activated. The target exercise intensity will 149 depend on the subject's self-rated score of Rating of Perceived Exertion of 150 approximately 13 in accordance with 60%-80% of maximum heart rate. 28

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The participants will start the exercise with an active warm-up for 10min to enhance 152 neuromuscular activation. In the succeeding 40 min, they will perform an aquatic 153 session, including abdominal bracing, vertical downward press, lateral downward 154 press, slant downward press, straight leg raising, treading water, and deep water 155 running. Finally, the participants will have a cool-down period for 10min. Table 1 156 shows the full description of the protocol.

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All subjects will participate in the exercise in a group of 8-9 people. Weeks 1 and 2 158 are the learning period for subjects to become familiar with the actions. Then, the 159 intensity of movements will be adjusted by changing the kickboard sizes. Thus, the 160 neuromuscular stimulation will be maximized, and the subjects' interest will also be 161 maintained.

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PTMs group 164 The subjects in the control group received TENS and IR irradiation therapy. Both The IR apparatus (model LY-607A Foshan Lingyuan Medical Technology Co., Ltd.,

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China) was placed with its lamp located 50 cm to 75 cm above the exposed area. The 174 lamp direction was adjusted to ensure that radiation struck the surface at or near a 175 right angle such that maximum penetration was achieved. 31,32 At 3-5 min after the 9 instrument was energised, the patient was asked whether their sense of warmth was 177 appropriate, and the lamp height was adjusted to prevent scalding.    PSQI is a self-reported scale that is used to assess sleep quality over a 1-month period.

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The PSQI consists of 19 individual items and comprises 7 components that are used chi-square test and analyze the continuous variables (e.g. age, height, weight, BMI, 291 and pain intensity) with independent t-test or Mann-Whitney U test to compare the 292 statistical significance between the TAE group and the PTMs group. The results of 293 descriptive statistics will be presented as mean ± standard deviation.

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The experimental results were compared through adjusted two-way repeated measures 295 ANOVA (group × time). The adjustment factors included gender, age, BMI, physical 296 activity, LBP duration, NRS of the most severe LBP, medication, and smoking history. problems and receive peer support. 9,11,49 TAE is a proactive and enjoyable treatment 312 to convey the positive health concept naturally, 50 which will cause long-term effects 313 by avoiding unhealthy behaviors, such as absence from work and prolonged rest. 11,51 314 Compared to PTMs, TAE can be carried out by patients themselves, which will cut 315 down the medical expenditure to some extent.

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To the best of our knowledge, this work is the first to compare the effect between 317 TAE and PTMs on patients with CLBP. Thus, our study may also have the potential 318 to optimize the strength of the water exercise, and our findings may provide broad 319 functional and psychological benefits to practical applications. First, the research duration of most previous studies typically ranged from several 323 weeks to 2 months. 22,23,[52][53][54] This study will include an intervention period of 3 months 324 and a follow-up period (without intervention) of 3 and 9 months, making the entire 325 term of 1 year. Second, our study will offer the same attention to all participants by 326 designing the two programs with equal time, thereby reducing other biases compared 327 with former studies. 55 Third, we will add some psychological scales and 328 lifestyle-related issues into our measurement. Thus, the CLBP will be accessed in a 329 multi-tiered system.