McDonough et al.

BMC Musculoskeletal Disorders 2010, 11:163

http://www.biomedcentral.com/1471-2474/11/163

STUDY PROTOCOL Open Access

The Back 2 Activity Trial: education and advice

versus education and advice plus a structured
walking programme for chronic low back pain
Suzanne M McDonough1*, Mark A Tully2, Seán R O’Connor1, Adele Boyd1, Daniel P Kerr1, Siobhán M O’Neill3,
Antony Delitto4, Ian Bradbury5, Catrine Tudor-Locke6, David G Baxter7, Deirdre A Hurley8

Abstract
Background: Current evidence supports the use of exercise-based treatment for chronic low back pain that
encourages the patient to assume an active role in their recovery. Walking has been shown it to be an acceptable
type of exercise with a low risk of injury. However, it is not known whether structured physical activity
programmes are any more effective than giving advice to remain active.
Methods/Design: The proposed study will test the feasibility of using a pedometer-driven walking programme, as
an adjunct to a standard education and advice session in participants with chronic low back pain. Fifty adult
participants will be recruited via a number of different sources. Baseline outcome measures including self reported
function; objective physical activity levels; fear-avoidance beliefs and health-related quality of life will be recorded.
Eligible participants will be randomly allocated under strict, double blind conditions to one of two treatments
groups. Participants in group A will receive a single education and advice session with a physiotherapist based on
the content of the ‘Back Book’. Participants in group B will receive the same education and advice session. In
addition, they will also receive a graded pedometer-driven walking programme prescribed by the physiotherapist.
Follow up outcomes will be recorded by the same researcher, who will remain blinded to group allocation, at
eight weeks and six months post randomisation. A qualitative exploration of participants’ perception of walking will
also be examined by use of focus groups at the end of the intervention. As a feasibility study, treatment effects
will be represented by point estimates and confidence intervals. The assessment of participant satisfaction will be
tabulated, as will adherence levels and any recorded difficulties or adverse events experienced by the participants
or therapists. This information will be used to modify the planned interventions to be used in a larger randomised
controlled trial.
Discussion: This paper describes the rationale and design of a study which will test the feasibility of using a
structured, pedometer-driven walking programme in participants with chronic low back pain.
Trial Registration: [ISRCTN67030896]

Background of exercise-based treatment programmes for chronic

Low back pain (LBP) has a high lifetime prevalence with LBP (CLBP pain persisting for at least 12 weeks) that
non-specific LBP representing the large majority of encourage the patient to assume an active role in their
cases [1]. Relapses in pain (60%) and work absences recovery [2]. Although the European Guidelines have
(33%) are common [1] leading it to be one of the most advocated exercise as the first line of treatment in the
costly conditions in the UK (total cost of £stg10,668 management of CLBP it is not clear which type of exer-
million) [1]. Current research evidence supports the use cise works best or what the ‘active ingredient’ of exercise
therapy is. Therefore, it has been suggested that much
more research is required to allow the development of a
* Correspondence: [email protected]
1
Health and Rehabilitation Sciences Research Institute, University of Ulster
Shore Road, Newtownabbey, Co Antrim, BT37 0QB, UK

© 2010 McDonough et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
McDonough et al. BMC Musculoskeletal Disorders 2010, 11:163 Page 2 of 8
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wider range of low cost, but effective exercise pro- use of pedometers in CLBP; research is required so that
grammes [1]. guidelines can be drawn up on how best to implement
There is however a significant challenge in encoura- this type of programme.
ging people with CLBP to become more physically It is not known whether this type of structured and
active as this group often exhibit fear avoidance beha- tailored motivational programme is likely to be more
viour, resulting in decreased physical activity (PA), in effective than simply giving the patient advice to remain
the belief that this will limit exacerbations in their LBP active and promoting self-management strategies via an
[3]. However given the evidence for the benefit of regu- educational booklet. Such booklets (e.g. the Back Book
lar exercise in people who cope with their CLBP, [17]), which are recommended by both the American
approaches that encourage and motivate long-term and European Guidelines [18,1], have been shown to be
lifestyle changes in PA are required [4]. A Cochrane similar or only slightly inferior in effectiveness to cost-
review of interventions that promote PA concluded that lier interventions (physiotherapy, supervised exercise
a mixture of professional guidance, self-direction and classes, yoga, spinal manipulation, acupuncture and
on-going professional support can encourage adults to massage) [17,19].
be more physically active [5]. One type of intervention
that has been shown to be effective in increasing PA Aim
and which incorporates these aspects is pedometer- The aim of the study is to test the feasibility of using a
driven walking [6]. structured, pedometer-driven walking programme, as an
Walking is an ideal intervention for physically inactive adjunct to a standard education and advice session in
individuals. In previous research, we have shown it to be patients with CLBP. This work will add to ongoing
a very acceptable type of exercise [7], as it does not research in this area by some of the team [15].
require training or equipment and can be undertaken in
an individual’s own locality and time [8], with little risk Specific objectives are as follows
of injury in sedentary, healthy individuals [9]. Recent i. To assess recruitment and adherence rates in educa-
walking initiatives, such as Walking the Way to Health tion and advice and education and advice plus walking
Initiative and the National Step-O-Meter campaign programme groups.
http://www.whi.org.uk have been advocated by the ii. To determine the incidence of adverse events,
Chartered Society of Physiotherapy [10]. The Step-O- including musculo-skeletal injuries, and level of overall
Meter campaign has focused on the recommendation satisfaction in both groups.
that individuals should accumulate 10,000 steps per day iii. To conduct a qualitative exploration of partici-
[11], using pedometers to set goals and record compli- pants’ experience of the walking plus education group.
ance [12]. Pedometers are simple to use, inexpensive iv. To make between and within group comparisons
devices which produce a user-friendly output (steps/ and estimate effect sizes for change in functional disabil-
day). A recent meta-analysis has shown they are effec- ity, PA levels, stage of change, fear-avoidance, self-
tive motivators to taking more activity and lead to efficacy, health-related quality of life, psychosocial
health improvements (reduction in blood pressure and beliefs, general health and participant satisfaction.
body mass index (BMI)) [13]. However, these findings
need to be extended from healthy sedentary middle- Methods/Design
aged adults to patient groups. Design
In the UK, anecdotal evidence suggests that people Single-blinded feasibility study.
with CLBP can reduce their pain through walking, and
practitioners are being encouraged to loan pedometers Ethical approval
in order to increase PA [10]. However, there is little evi- Ethical approval for the trial has been granted by The
dence to guide this practice. Only one published study Office for Research Ethics Committees (Northern
has investigated walking (unsupervised or monitored), Ireland) [Ref No. 09/NIR01/49]. All patients who agree
the outcomes of which were less effective than those fol- to take part will be required to give informed written
lowing physiotherapy or exercise therapy [14] and consent prior to participation in the study.
another trial is ongoing [15]. In contrast one study (of
chiropractic versus medical management) suggested that Study population
those engaged in additional unsupervised brisk walking 50 adult participants (Male or Female; aged 18 years or
(>3 hours per week) had a better outcome [16]. Limited over) with LBP persisting for at least twelve weeks will
conclusions can be drawn from these studies as partici- be included in the study. Participants will be recruited
pants did not receive a structured walking programme. through a number of different sources using previously
Therefore, given that there are no previous trials of the employed methods [20].
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Identification of potential participants and screening letter was sent. No further contact will be made after
procedures this stage with individuals who indicate that they do not
In order to maximise recruitment and to ensure that the wish to take part. Those who do respond positively to
sample size is achieved, potential participants will be the invitation letter or telephone call from CTP will
identified from a number of sources. then be contacted separately by telephone and screened
I) The Physiotherapy department at the Robinson for eligibility by a member of the local research team.
Memorial Hospital, Ballymoney will serve as one recruit- Those meeting the inclusion criteria will then be sent a
ment source. Potential participants will be identified second letter with an appointment time arranged for
from the referral lists and sent a letter inviting them to approximately one week after telephone screening. This
take part in the research study. This letter will state is in order to allow an adequate ‘cooling-off’ period dur-
clearly that the individual is under no obligation to take ing which the individual can fully consider their partici-
part in the study and that non-participation will not pation in the study.
prevent them from still receiving a standard physiother- III) A third potential source for recruitment will be
apy appointment after the 9-13 week waiting list. The 8 identification of participants via Occupational Health or
week intervention period of the study therefore fits via email/poster advertisements to staff and students at
within this timescale. Interested participants will contact the University of Ulster.
the Physiotherapy department to arrange an initial At the first appointment, a full verbal explanation of
appointment time. They will then be sent a confirmation the study procedures will be provided and eligibility to
letter and information sheet which will allow for a ‘cool- participate confirmed using the inclusion and exclusion
ing off’ period of approximately one week. criteria shown in table 1. Written informed consent will
II) Retrospective searches of computerised records of then be sought from eligible participants. At this stage a
local General Practices will be conducted by practice final exclusion criteria will be applied. Apparently eligi-
staff with the assistance of the Clinical Trials Practi- ble participants will be fitted with an activPAL physical
tioner (CTP) from the Northern Ireland Primary Care activity monitor (PAL Technologies, Glasgow, UK) for
Research Network (PCRN). Potential participants will be one week. This is in order to provide an objective mea-
sent an invitation letter and information sheet from the surement of PA levels and to confirm that the individual
study team along with a covering letter from their GP. does not have a pre-existing high level of PA. This will
Potential participants will be asked to complete an be determined according to previously defined daily step
enclosed reply slip indicating their interest in being con- count categories [11]. To meet the final criteria for elig-
tacted by a member of the research team with a view to ibility, the individual must be taking less than an average
taking part in the study. They will also have the oppor- of 8,500 steps/day. Participants meeting the criteria
tunity to indicate that they are not interested in the outlined above will then be invited back one week later
study and do not wish to be contacted further using the to begin the intervention period of the study. Details of
same reply slip. Potential participants who do not return the recruitment, screening and study procedures are
the reply slip will also be followed up by a telephone outlined in Additional file 1. Participants recruited via
call from the CTP at least two weeks after the invitation method I will receive the intervention in the

Table 1 Inclusion and exclusion criteria

Inclusion Exclusion
Males and females aged 18 years or over Any spinal surgery in the past twelve months
LBP with/without radiation persisting for greater than 12 Evidence of nerve root, spinal cord, or cauda equina compression, severe spinal
weeks. stenosis indicated by signs of neurogenic claudication, Grade 3-4 spondylolisthesis,
(Grade 1-2 spondylolisthesis eligible for inclusion) fibromyalgia or systemic/
inflammatory disorder
Capable of participating in home based exercise as indicated Any other current musculoskeletal injury or contraindication to increasing physical
by their GP [home based, walking intervention] activity levels, including any cardio-respiratory or other medical condition limiting
exercise tolerance
Fluency in English (verbal and written) Any history of epilepsy
LBP caused by involvement in a road traffic accident in the last 12 months or
ongoing litigation
History of serious Psychological or Psychiatric illness (mild depression eligible for
inclusion)
Current Pregnancy
High activity levels categorised according to objective physical activity levels (7 day
ActivPAL recording)
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Physiotherapy department while participants recruited PA items will be recorded. This method has previously
via methods II and III will receive the intervention in been employed in other CLBP studies [20,29].
the research centre at the University of Ulster. Back Beliefs questionnaire (BBQ) The primary objec-
tive of the BBQ is to assess the individual’s beliefs about
Baseline outcome measurements various aspects of the future as a consequence of LBP.
Baseline recording of all outcome measures shall be car- The scale comprises nine inevitability statements, along
ried out by the same researcher prior to randomisation. with five statements used as distracters. The scale is cal-
culated by reversing and summing the 9 inevitability
Outcome Measures measure scores. The scale has been shown to have good
Primary outcome internal validity (Chronbach’s Alpha = 0.70) and reliabil-
Functional disability This will be assessed using the ity (Intraclass Correlation Coefficient = 0.87) [30].
Oswestry Disability Questionnaire (ODQ). This has Physical Activity Self-efficacy Scale Self-efficacy was
been shown to be a valid and reliable measure of pain assessed using the five point scale proposed by Marcus
and physical function in LBP patients [21]. The ODQ et al [31]. Perceived self-efficacy is described as the
consists of 10 sections, each with six levels (with a maxi- belief or the confidence in owns own ability to perform
mum score in each section of five points) that assess the a behaviour necessary to reach a desired goal or achieve
individual’s limitations in various activities of daily an expected outcome[32]. Self efficacy is regarded as an
living. The sum of all 10 sections is divided by the total important factor in the self-management of chronic con-
possible score and the result multiplied by 100 to gener- ditions and is highly correlated with disability [33].
ate a percentage score. Values range from 0 (best health Pain Pain will be assessed using a numerical rating scale
state) to 100 (worst health state) with an average score (0-10). Participants will be instructed to select a number
of 43% identified for chronic back pain participants between 0 and 10 that best describes their pain over the
[21-23]. A minimum important change of between last seven days with 0 meaning ‘No pain’ and 10 mean-
10-12 points over time, or an improvement from base- ing the ‘Worst pain imaginable’ [24].
line of between 20-30% for an individual patient has Health-related quality of life This will be measured
been recommended [24]. using the EuroQol-5D [34], a self-administered ques-
Secondary outcomes tionnaire that assesses the participant’s health-related
PA Level Objective change in PA levels will be mea- quality of life using a core set of five health-related
™
sured using an activPAL professional physical activity quality of life items [35]. Its validity and reliability are
logger (PAL Technologies, Glasgow, UK). The activPAL supported, and it has been recommended for use in low
is a small device (5 × 3 cm) containing a uni-axal accel- back pain research [36]. For the UK population, an aver-
erometer which provides a valid and reliable measure of age weighted health index of 0.86 and self-rated health
steps taken, cadence and time spent lying/sitting, stand- status of 82.48 have been reported in the literature [37].
ing and stepping under free-living conditions. Reported Use of this outcome along with the information col-
ICCs for inter-device reliability range from 0.79-0.97 lected on use of health care resources will facilitate a
(CIs not stated) [25]. The monitor will be attached to cost-utility analysis of the trial interventions.
the participant’s anterior thigh using PALstickies and ™ Health Care Usage This will be assessed using a ques-
reinforced with Vulcan fixation tape (Mobilis Healthcare tionnaire developed by members of the research team
Group Limited, Oldham, Lancashire, UK). The device in conjunction with a Health Economist. This tool
will be worn for seven consecutive days at each time- has successfully been employed during a previous
point (baseline, eight weeks and 24 weeks). Each partici- study [20].
pant will also complete the IPAQ (short form) at each Global Rating of change for physical activity [38]. At
time point [26]. The IPAQ asks the participant about baseline participants will be asked to rate their ability to
the time they spent being physically active in the last be more physically active compared to the previous
seven days. week. This will be recorded as No change, Worse or
Stage of Change Readiness to change will be assessed Better. If they answer Worse or Better, they will be
using a standardised questionnaire, which describes an asked to indicate how much it is worse or better using
individual’s position in a cycle of change described one of the following markers: A tiny bit - almost the
within the Prochaska and Diclemente framework [27]. same; A little bit; Somewhat; Moderately; Quite a bit, A
Fear-Avoidance Beliefs - Physical Activity Assessed great deal or A very great deal. They will also be asked
using the Fear-Avoidance Beliefs Questionnaire (FABQ): to rate how important this change or lack of change is
The FABQ is a 16 item self-report questionnaire that to them using the same markers. At each follow up
specifically focuses on participants’ beliefs about how assessment, participants will be asked to give a rating
PA and work affect their low back pain [28]. Only the compared to the last time point.
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Prior to randomization, each participant’s preference group A. In addition, they will also receive a graded
for which treatment they would like to receive will be pedometer-driven walking programme prescribed by the
recorded. Expectations of assigned treatment will also physiotherapist. Each participant will be given a ped-
be recorded using a Likert Scale [20]. On completion of ometer (Yamax Digiwalker CW-701, Yamax, Japan) to
the trial a participant satisfaction questionnaire will be monitor their activity. This has been shown to be the
administered to ascertain views on the interventions and most reliable, commercially obtainable pedometer which
perception of benefit [20]. is currently available [39]. Participants will have the ped-
ometer for a one week familiarisation period before they
Treatment allocation return for their next appointment. At this appointment
A statistician who will have no contact with the day to the specific content of the tailored intervention will
day running of the study shall carry out all aspects of pre- begin. This will be determined according to the 5A’s
paration for group randomisation. A randomisation model of health behaviour advice. This model was
sequence will be generated using computer software with developed for brief smoking cessation advice but has
an allocation ratio of 1:2. This is order to ensure more also been proposed as a tool by which clinicians work-
information can be gathered on the walking intervention ing in a primary care setting might provide advice
group (Group B). This is relevant since we wish to gather aimed at influencing other health related behaviours,
as much detail as possible regarding adverse events or including PA [40]. The 5A’s are as follows: Ask, Assess
other side effects and will enable us to learn more about willingness to change, Advise, Assist, and Arrange
the type and level of training required for this interven- follow-up. During the study the model will therefore be
tion in a fully powered trial. Blank cards will be printed applied in treatment group B according to the following
with Group A (Education and advice) or Group B (Edu- format.
cation and advice plus a structured walking programme). 1) Ask: Participants will be asked about their current
These cards will be placed inside sequentially numbered PA and exercise history. 2) Assess: Participants current
opaque sealed envelopes. Following baseline assessment, level of motivation to exercise will be measured using
these envelopes will be used to assign participants in the readiness to change questionnaire which will have
sequence to one of the two treatment groups (Group A been recorded at baseline. Individuals in pre-contempla-
or Group B). Participants will therefore be randomised tion will be asked their reasons for taking part in the
under strict double-blind conditions. trial and their barriers to further activity. They will then
be asked how they feel about their exercise levels and if
Treatment protocols they are willing or ready to try a bit more. 3) Advise:
Education & advice (Group A) Participants will be given further advice on the benefits
Participants in the Education and advice group will of PA for their back pain. This will be delivered using
receive a single, one to one session with a physiothera- personalised but non-judgmental language. This will be
pist who will complete a physical examination and give based on the participant’s responses to question 1 and
standardised advice using the ‘Back Book’ [17]. The aim will make reference to the information in the ‘Back
of the session will be to encourage a graded return to Book’. 4) Assist: Participants will be given additional
normal activities. Specifically the session will address the advice which will include an explanation of the use of
causes of low back pain, as well as giving advice on how pedometers to set individual goals and how this may be
to deal with an attack of back pain, the nature of used to maintain motivation. There will then be a 10
chronic pain and how to better cope with these issues. minute self-efficacy walk, during which the participant
All participants will be given a copy of the Back Book to will wear the pedometer while the physiotherapist will
keep. This will have a contact telephone number for the discuss aspects of walking as a form of PA (such as foot-
physiotherapist printed on the inside of the front cover. wear and safety) as well as reinforcing some of the pre-
Participants will be encouraged to contact the phy- viously discussed aspects of the intervention. This will
siotherapist to seek advice or address any further ques- be followed by a brief discussion during which an initial,
tions that they may have at a later date during the weekly step goal will be determined by negotiation. This
intervention period. If they wish the participants can will be set using the Goal Attainment Scale (GAS). This
leave a message for the physiotherapist who will call is order to place the step goal in a context which relates
them back using a standardised telephone script adapted to the participants own circumstances. Participants will
from a previous study [20]. be asked to rate their perception of the likelihood of
Education & advice plus a structured walking programme achieving the weekly goal on a scale of 0-10. If they rate
(Group B) the scale as below 8, the target will then be re-
Participants in Group B will receive the same single negotiated in order to reach a target which is seen as
education and advice session as described above for realistic by both the physiotherapist and participant.
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Lastly, the physiotherapist will demonstrate how to Sample size

record daily step counts and any adverse events in a No formal sample size calculation will be carried out. As
diary. This will also be used to determine compliance a feasibility study, we aim to recruit a total sample of 50
which will be based on the participants self-reported participants (Approximately 17 in Group A and 33 in
weekly step counts and recorded by the physiotherapist Group B according to the 1:2 randomisation methods).
as a percentage of the target number of steps completed. This sample size reflects both a realistic target for the
5) Arrange follow-up: Appropriate follow-up and sup- intervention period and one which we anticipate will
port will then be arranged. This will involve a discussion provide sufficient information on the interventions to
of a follow-up date or time frame to assess progress, to inform future studies. In particular, we are interested in
assist in overcoming difficulties and to reassess daily gathering as much information as possible on any
step goals. To encourage compliance, participants will adverse events (including minor musculoskeletal inju-
receive a weekly telephone call from a physiotherapist ries) associated with the walking intervention. Two
using a pre-determined script (approximately 10-15 reported adverse events in the walking group will repre-
minutes). During this conversation, difficulties will be sent an approximate incidence of 5%.
addressed, data from the pedometer recorded and a new
walking goal set. This approach has been previously Statistical analysis
employed in other walking intervention studies [41]. In As a feasibility study, significance tests will not be per-
addition, participants will be encouraged to contact the formed or reported for the primary or secondary out-
physiotherapist if they have any other questions or con- comes. Treatment effects will be represented by point
cerns at any other time during the intervention period. estimates and confidence intervals. The assessment of
The specific features of the five components will be participant satisfaction will be tabulated, as will adher-
recorded for each participant in a standardised manner. ence levels and any recorded difficulties or adverse
events experienced by the participants or therapists.
Follow-up procedure This information will be used to modify the planned
Follow up measurements of all outcome measurements interventions to be used in the main RCT. The follow-
will be recorded at eight weeks (on completion of trial) ing criteria would suggest that a main trial is not feasi-
and at six months after randomisation into the trial by a ble: no apparent change in the outcomes with
member of the research team who shall remain blinded confidence intervals that include large negative values,
to group allocation throughout the study. feedback from participants that they were unable to
complete (or lack of adherence with) the walking pro-
Focus Groups gramme and/or unable to use the pedometers; high
Qualitative exploration of individuals’ perception of walk- levels of musculoskeletal injuries occurring.
ing will also be examined by use of focus groups at the
end of the intervention. Participants in group B will be Adverse event recording
invited to one of three to five groups, consisting of Any adverse events will be reported using a standard
between 5 and 8 participants, to discuss their experiences, proforma.
expectations and satisfaction with the walking programme.
Each focus group will consist of a maximum of eight parti- Service user involvement
cipants and will take place over a two-hour period. A ‘clue Two service users will sit on the research team panel
and cue process’, using a checklist of topics, will be used during the developmental and running stages of the
to ensure that the same basic areas are covered, but allow- study.
ing any issues of importance to emerge. Sessions will be
moderated by an experienced, independent focus group Training requirements
moderator who will have had no previous contact with Both service users will attend two separate training
study participants prior to the focus group meetings. sessions at the research centre to familiarise themselves
Audio-tape recordings and field notes will be prepared by with the study procedures. In addition, all physiothera-
another member of the research team not involved in the pists involved in delivering the interventions will receive
running of the trial. Interviews will be transcribed, and a standardised period of training prior to commence-
interpretation, synthesis and data reduction undertaken ment of the study.
independently by two members of the research team. Ana-
lysis will then be undertaken using qualitative research and Discussion
data analysis software (N-VIVO [QDSR]). The findings This paper describes the rationale and design of a study
will be presented to participants and therapists for their which will test the feasibility of using a structured, ped-
feedback and to help inform further research. ometer-driven walking programme in participants with
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CLBP. This study will be to provide important practical programmes at and below current recommended levels of exercise in
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Acknowledgements conventional physiotherapy and self exercise in patients with chronic
The authors gratefully acknowledge project funding for this trial from the low back pain. Spine 1998, 23:2616-2624.
Physiotherapy Research Foundation, Chartered Society of Physiotherapy, UK 15. Hurley DA, O’Donoghue G, Tully MA, Moffett JK, van Mechelen W, Daly L,
and funding for a PhD studentship from the Department of Employment Boreham CA, McDonough SM: A walking programme and a supervised
and Learning, Northern Ireland. The authors would also like to acknowledge exercise class versus usual physiotherapy for chronic low back pain: a
and thank Miss Sharon McCaffrey and Mr David Dodds for their help and single-blinded randomised controlled trial. (The Supervised Walking In
support in their role as service users in the trial. comparison to Fitness Training for Back Pain (SWIFT)Trial). BMC
Musculoskelet Disord 2009, 10(79).
Author details 16. Hurwitz EL, Morgenstern H, Kominski GF, Yu F, Chiang LM: A randomised
1
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Excellence for Public Health (NI), Queens’ University Belfast, UK. 3School of study. Spine 2006, 15;31(6):611-21.
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Science, University of Pittsburgh, USA. 5Frontier Science, UK. 6Walking to patients with back pain can have a positive effect. A randomized
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Zealand. 8School of Public Health, Physiotherapy and Population Science, 18. Chou R, Huffman LH, American Pain Society; American College of
University College Dublin, Ireland. Physicians: American Pain Society; American College of Physicians.
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Authors’ contributions review of the evidence for an American Pain Society/American College
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Competing interests auricular acupuncture: a pilot assessor-blind randomised controlled trial.
The authors declare that they have no competing interests. (The acupuncture and personalised exercise programme (APEP) trial).
BMC Musculoskelet Disord 2008, 6;9:31.
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2474/11/163/prepub

doi:10.1186/1471-2474-11-163
Cite this article as: McDonough et al.: The Back 2 Activity Trial:
education and advice versus education and advice plus a structured
walking programme for chronic low back pain. BMC Musculoskeletal
Disorders 2010 11:163.

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