49033

cle2014
CRE0010.1177/0269215514549033Clinical RehabilitationPires et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

Aquatic exercise and pain 2015, Vol. 29(6) 538­–547

© The Author(s) 2014
Reprints and permissions:
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DOI: 10.1177/0269215514549033

aquatic exercise alone for patients cre.sagepub.com

with chronic low back pain: a

randomized controlled trial

Diogo Pires1, Eduardo Brazete Cruz2 and Carmen

Caeiro2

Abstract
Objective: The aim of this study was to compare the effectiveness of a combination of aquatic exercise
and pain neurophysiology education with aquatic exercise alone in chronic low back pain patients.
Design: Single-blind randomized controlled trial.
Setting: Outpatient clinic.
Subjects: Sixty-two chronic low back pain patients were randomly allocated to receive aquatic exercise
and pain neurophysiology education (n = 30) or aquatic exercise alone (n = 32).
Interventions: Twelve sessions of a 6-week aquatic exercise programme preceded by 2 sessions of
pain neurophysiology education. Controls received only 12 sessions of the 6-week aquatic exercise
programme.
Main measures: The primary outcomes were pain intensity (Visual Analogue Scale) and functional
disability (Quebec Back Pain Disability Scale) at the baseline, 6 weeks after the beginning of the aquatic
exercise programme and at the 3 months follow-up. Secondary outcome was kinesiophobia (Tampa Scale
of Kinesiophobia).
Results: Fifty-five participants completed the study. Analysis using mixed-model ANOVA revealed a
significant treatment condition interaction on pain intensity at the 3 months follow-up, favoring the
education group (mean SD change: –25.4± 26.7 vs –6.6 ± 30.7, P < 0.005). Although participants in the
education group were more likely to report perceived functional benefits from treatment at 3 months
follow-up (RR=1.63, 95%CI: 1.01–2.63), no significant differences were found in functional disability and
kinesiophobia between groups at any time.
Conclusions: This study’s findings support the provision of pain neurophysiology education as a clinically
effective addition to aquatic exercise.

1Polytechnic Institute of Castelo Branco – Physiotherapy Corresponding author:

Department, School of Health Care, Castelo Branco, Portugal Diogo Pires, Escola Superior de Saúde Dr. Lopes Dias,
2Polytechnic Institute of Setúbal – Physiotherapy Department, Avenida do Empresário - Campus da Talagueira 6000 - 767
School of Health Care, Setúbal, Portugal Castelo Branco, Portugal.
Email: diogo.pires@ipcb.pt
Pires et al. 539
Keywords
Education, chronic low back pain, exercise, pain, disability
Received: 7 May 2014; accepted: 3 August 2014
Introduction
Chronic low back pain is a common condition
across western countries.1,2 This condition has
been referred as the main cause of functional disa-
bility and work absenteeism, presenting consider-
able costs to individuals, health systems and their
economies.2,3 In approximately 90% of chronic
low back pain patients, a specific cause for the
symptoms cannot be assigned, being described as
non-specific chronic low back pain.4,5
A significant proportion of chronic low back pain
patients, search for physiotherapy care to relieve
pain and increase functional capability.4,6 Research
has suggested that exercise is effective in the treat-
ment of chronic low back pain, regardless the char-
acteristics of the exercise selected.7,8 Although the
literature describes different types of exercise pro-
grammes, aquatic exercise is one of the most used
modalities across clinical practice settings in
Portugal. Several studies have demonstrated posi-
tive results in reducing pain intensity and functional
disability in chronic low back pain patients, at least
identical to land exercise programmes.9,10
However, (aquatic) exercise as intervention alone
does not seem to take into consideration the mala-
daptive pain cognitions and illness behavioural
characteristics frequently identified in chronic low
back pain patients. Previous studies have identified
factors, such as kinesiophobia or catastrophizing, as
a poor outcome prognostic factors for improvements
in pain intensity11 and functional disability12,13 fol-
lowing physiotherapy. Thus, there are recommenda-
tions for modifying these factors through educational
programmes14-16 to optimise the outcomes of other
interventions, such as exercise.17
Pain neurophysiology education is a cognitive
behavioural intervention that uses the explanation
of pain neurophysiology to change maladaptive
pain cognitions, illness perceptions or coping
strategies, to further introduce normal movement
and activity, and reducing pain and functional dis-
ability.18 Pain neurophysiology education has been
shown to be effective in the treatment of chronic
low back pain when used as a single intervention19
as well as when combined with other modalities.20
However, little is known about the real impact on
the outcomes when adding pain neurophysiology
education to aquatic exercise. Therefore, the aim of
this study was to compare the effects of an aquatic
exercise programme and pain neurophysiology
education with an aquatic exercise programme
alone, on pain intensity, functional disability and
kinesiophobia, in chronic low back pain patients.
Methods
A parallel single blinded randomized controlled
trial was used with each participant being randomly
assigned to receive an aquatic exercise programme
and pain neurophysiology education (education
group) or an aquatic exercise programme alone
(control group) using a balanced block randomiza-
tion method with blocks of three or six participants.
Participants were allocated to a group by the cen-
tral telephone registration service of the outpatient
clinic, thus ensuring allocation concealment.
The sample size and power calculations were
performed with MedCalc software statistical pro-
gramme (MedCalc Software bvba, 2013). The cal-
culations were based on detecting a minimal
clinically important difference of 20 points on the
0–100 Visual Analogue Scale at follow-up,21
assuming a standard deviation of 22 points, a
2-tailed test, an alpha level of 0.05, and a desired
power of 90%. These assumptions generated a
sample size of a minimum of 26 participants per
group.
540 Clinical Rehabilitation 29(6)
Participants
Participants were recruited from the waiting list of a
Portuguese outpatient clinic, between September
2012 and June 2013. Participants were eligible if
they had low back pain for at least three months,4
with or without pain referred to the leg, were aged
between 18 and 65 and were literate in Portuguese.
They were excluded if they had a specific cause for
low back pain, such as: 1) clinical signs of infection,
tumour, osteoporosis, fracture, structural deformity,
inflammatory disorder (e.g. ankylosing spondylitis),
radicular syndrome, or cauda equine syndrome;22 2)
history of back surgery or conservative treatment in
the prior six and three months, respectively; 3) preg-
nancy;23 4) cardiac and/or respiratory condition
impediment to physical exercise.22
The inclusion/ exclusion criteria were con-
firmed by a previously trained physiotherapist,
blinded to the study’s objective and procedures.
Finally, eligible participants gave their written
informed consent after receiving oral and written
information about the study. Ethics approval was
obtained from the Ethics Committee of the host
University.
Intervention protocol
All participants performed a 6-week programme
consisting of 12 sessions of aquatic exercise.
Additionally, the education group received two
sessions of pain neurophysiology education
immediately before starting the aquatic exercise
programme.
The aquatic exercise program consisted of 12 bi-
weekly sessions carried out in a therapeutic pool at
33°C. Each session was carried out including a
group of six to nine participants and lasted between
30 to 50 minutes. Overall, these sessions were
divided into three phases: 1) warm-up phase; 2)
specific exercises phase; and 3) warm-down phase.
The exercises included in each phase were based on
the aquatic exercise program for chronic low back
pain patients described by Dundar and colleagues.9
The pain neurophysiology education programme
consisted of two group sessions (90-minute each)
and was based on the contents and guidelines
described by Butler and Moseley24 and Nijs et al.18
The topics addressed included: acute pain origin in
nervous system; transition from acute to chronic
pain; central sensitization; the role of the brain in
the perception of pain; psychosocial factors related
to pain; cognitive and behavioural responses related
to pain; flare-up management and pacing.18,24
Metaphors and pictures were used to challenge the
participants` maladaptive pain cognitions and ill-
ness behaviours, throughout the sessions.
Outcome measures
The primary outcomes were pain intensity
(throughout the last week) measured by the Visual
Analogue Scale25 and functional disability meas-
ured by the Portuguese version of the Quebec Back
Pain Disability Scale.26
The Visual Analogue Scale is a self-reported out-
come measure that provides a score for the level of
pain intensity, ranging from no pain (0 mm) to
unbearable pain (100 mm). It has been shown to be
reliable, with the intra-class correlation coefficient
(ICC) ranging from 0.71 to 0.99, and valid with con-
struct convergent validity values of r = 0.71–0.78
when compared to other pain assessment tools.27,28
A change of 20 or more points was identified as the
minimal clinically important difference in a sample
of Portuguese chronic low back pain patients.21
The Quebec Back Pain Disability Scale consists
of 20 items, in which patients are asked to rate their
degree of difficulty in performing a specific activ-
ity from 0 ('not difficult at all') to 5 ('unable to do')
in each item. The Quebec Back Pain Disability
Scale score ranges from 0 to 100, with higher val-
ues indicating higher levels of disability. It has
shown good internal consistency (Cronbach’s α =
0,95), reliability (ICC= 0,696), and construct valid-
ity (ρ = 0.62; P < 0.001 with the Roland Morris
Disability Questionnaire; ρ = 0.38; P < 0.001 with
the Visual Analogue Scale).26 A change of 7 or
more points was identified as the minimal clini-
cally important difference in a sample of Portuguese
chronic low back pain patients.29
Secondarily, kinesiophobia was assessed by the
Portuguese version of Tampa Scale of Kinesiophobia.
It is a 13 items questionnaire, rated through a 4 point
Pires et al. 541
Likert scale ranging from ‘strongly disagree’ to
‘strongly agree’. Total score ranges from 13 to 52,
with higher scores indicating higher levels of kinesi-
ophobia. The Tampa Scale of Kinesiophobia has
demonstrated good internal consistency in a chronic
low back pain population (Cronbach’s α = 0,82).30
Participants were assessed at the baseline, 6
weeks after the beginning of the aquatic exercise
programme and at 3 months follow-up, by an exter-
nal assistant blinded to the participants’ groups.
Statistical analysis
Data analysis was performed using the Statistical
Package for the Social Sciences Version 20.0 (IBM
Corporation, Chicago, IL). A level of significance
of p ≤ 0.05 was set for this study.
Clinical and sociodemographic baseline varia-
bles, including pain intensity and functional disabil-
ity scores, were compared between groups by using
the independent t tests for continuous data and chi-
square tests of independence for categorical data.
Data was assessed for outliers, normality, homo-
geneity of variances and covariances. The changes in
Visual Analogue Scale, Quebec Back Pain Disability
Scale and Tampa Scale of Kinesiophobia scores were
examined using two-way mixed-model ANOVA
with treatment condition (education or control) as
between-subjects factors and time as a within-sub-
jects factor. In all the cases data was analyzed accord-
ing to the intention to-treat analysis principle using
multiple imputation of the missing values.31,32
Lastly, relative risks and the corresponding 95%
CI were calculated to assess the differences
between groups for perceived benefit of physio-
therapy (pain intensity and functional disability
improvements above the minimal clinically impor-
tant difference). Additionally, chi-square tests were
also used to determine whether or not there was a
difference between the groups for the proportion of
participants reporting perceived benefits.
Results
Participants
Of the 86 participants assessed for eligibility, 24
were excluded for not meeting the inclusion/ exclu-
sion criteria (n=15), for not accepting to integrate
the study (n=6) or for other reasons such as, incom-
patible schedules (n=3) (see Figure 1).
Baseline characteristics of the 62 participants
included in the study are presented in Table 1. At
the baseline, there were no significant differences
between the groups for any of the sociodemo-
graphic and clinical variables.
Of the 62 participants who were randomly
assigned, six (one in the education group and five
in the control group) withdrew sometime during
the 6-week treatment period. All dropouts were due
to the participant’s temporary illness or personal
issues. There were no adverse effects associated
with the intervention programmes.
Dropout participants showed similar characteris-
tics of those completing the study. The only excep-
tion was the baseline mean score of the Quebec
Back Pain Disability Scale in the control group, with
the five dropout participants reporting higher levels
of functional disability (46.8 ± 14.9 vs 24.6 ± 10.3).
To be included in the statistical analyses, par-
ticipants had to complete eight (75%) or more ses-
sions of aquatic exercise and the two educational
sessions. None of the participants was excluded for
this reason. Participants in the education group
attended a mean of 11.0 (±0.9) out of the 12 planned
exercise sessions compared with 11.3 (±1.0) ses-
sions in the control group.
Treatment effects/outcomes
Significant differences were found for the overall
group by time interaction in the mixed ANOVA,
for pain intensity F(2,120) = 4.699, P < 0.05 and
functional disability, F(2,120) = 5.415, P < 0.05,
but no statistical interaction effects were found for
kinesiophobia. Moreover, there was a statistically
significant difference in pain intensity between
groups at the 3 months follow-up, F(1,60) = 8.404,
P< 0.05. The reduction in pain intensity was statis-
tically significantly greater in the education group,
compared to the control group. No statistically sig-
nificant differences were found between groups at
6 weeks post intervention (P = 0.14). In what con-
cerns to functional disability, no statistically sig-
nificant differences were found between groups at
6 weeks post intervention (P = 0.83) and at the 3
months follow-up (P = 0.09) (Table 2).
542 Clinical Rehabilitation 29(6)

Assessed for eligibility (n=86)

Excluded (n=24)
• Not meeting inclusion criteria
(n=15)
• Declined to participate (n=6)
• Other reasons (n=3)

Randomized (n=62)

Allocated to educaon group (n=30) Allocated to control group (n=32)

Post 6-weeks intervenon Post 6-weeks intervenon

(n=29); 1 drop out (n=27); 5 drop out

Post 3-months follow-up Post 3-months follow-up

(n=29) (n=26); 1 drop out

Analysed (n=30) Analysed (n=32)

Figure 1.  Flowchart of the study.

Table 1.  Baseline demographics for both groups (raw and percent).

Education group (n= 30) Control group (n= 32) P-value

Age (years) 50.9 ±6.2 51.0 ±6.3 0.968b
Gender (n; %) Female 20 (66.7%) 20 (62.5%) 0.732a
Male 10 (33.3%) 12 (37.5%)
Body mass index 26.3 ±2.9 26.7 ±3.4 0.394c
Education (n; %) Primary-Basic 10 (33.3%) 15 (46.9%) 0.546a
High School 10 (33.3%) 8 (25.0%)
University 10 (33.3%) 9 (28.1%)
Working status (n; %) Active 22 (73.3%) 23 (71.8%) 0.898a
Not active 8 (26.7%) 9 (28.2%)
Medication (n; %) Yes 8 (26.7%) 5 (15.6%) 0.286a
No 22 (73.3%) 27 (84.4%)
Duration of pain (n; %) 3 – 24 months 6 (20.0%) 8 (25.0%) 0.638a
> 24 months 24 (80.0%) 24 (75.0%)
Pain referred to the leg (n; %) Yes 15 (50.0%) 19 (59.4%) 0.459a
No 15 (50.0%) 13 (40.6%)
Pain intensity (0–100) 43.4 ±22.9 42.4 ±21.2 0.855b
Functional disability (0–100) 32.3 ±13.9 28.0 ±13.6 0.231b
aAnalysed by the chi-squared test; banalysed by the student t test; canalysed by the Mann-Whitney U test.
Pires et al. 543

Table 2.  Pain and functional disability scores at post-intervention and 3-month follow-up. Change difference (6
weeks post-intervention – baseline; 3 months post-intervention – baseline). Data are presented as mean ± standard
deviation.

Groups Baseline 6 weeks Change baseline 3 months Change baseline

to 6 weeks to 3 months
Education group (n= 30)  
VAS (0–100) 43.4 ±23 20.6 ±19 –22.8 ±26.6 18.0 ±19 –25.4 ±26.7
QBPDS-PT (0–100) 32.3 ±14 21.2 ±15.8 –11.1 ±15.8 19.2 ±14.8 –13.1 ±16.2
TSK-13 (13–52) 28.6 ±6 25.2 ± 4.7 –3.4 ± 5.3 23.2 ±6.3 –5.4 ± 6.1
Control group (n= 32)  
VAS (0–100) 42.4 ±21.2 27.6 ±17.2 –14.8 ±17.2 35.8 ±28 –6.6 ±30.7
QBPDS-PT (0–100) 28.1 ±13.6 20.4 ±12.3 –7.7 ±10.6 25.9 ±15.7 –2.2 ±13.2
TSK-13 (13–52) 29.1 ±5.6 27.5 ±6.2 –1.7 ± 6.7 26.5 ±7.9 –2.7 ± 6.8

VAS: Visual Analogue Scale; QBPDS-PT: Portuguese version of the Quebec Back Pain Disability Scale; TSK-13: Tampa Scale of
Kinesiophobia.

Table 3.  Number and proportion of participants showing a minimal clinically important change in pain intensity
and functional disability at post-intervention and 3-month follow-up for the education group and control group.
Relative Risk and comparative analysis.

Outcomes Time MCID Education Control group; Relative risk (CI 95%) P-value a
group; n (%) n (%)
Pain intensity 6 weeks Benefit 17 (58.6%) 10 (37.0%) 1.58 (0.89–2.82) 0.106
No benefit 12 (41.4%) 17 (63.3%)
3 months Benefit 17 (58.6%) 11 (40.7%) 1.44 (0.83–2.50) 0.181
No benefit 12 (41.4%) 16 (59.3%)
Functional disability 6 weeks Benefit 18 (62.0%) 12 (44.4%) 1.40 (0.84–2.32) 0.186
No benefit 11 (38.0%) 15 (55.6%)
3 months Benefit 21 (72.4%) 12 (44.4%) 1.63 (1.01–2.63) 0.034*
No benefit 8 (27.6%) 15 (55.6%)

MCID: minimal clinically importance difference; CI: Confidence Interval; *significant at P<0.05; aanalysed by chi-squared test.

Participants in the education group were more
likely to report benefits from treatment on pain
intensity and functional disability at all time points
than participants in the control group. However, and
with the exception of functional disability measured
at the 3 months follow-up (P = 0.034), no signifi-
cant differences between-group were found con-
cerning the proportion of participants who attained
the minimal clinically important difference in pain
intensity and functional disability (Table 3).
Discussion
This study’s findings consistently favoured the
addition of pain neurophysiology education before
undertaking the aquatic exercise programme for
the reduction of pain intensity and functional disa-
bility in patients with chronic low back pain when
compared to the aquatic exercise programme alone.
There is a trend for the education group to score
better than the control group at the 6 weeks post-
intervention and at the 3 months follow-up, how-
ever statistically significant differences between
these groups were only found in pain intensity and
at the 3 months follow-up.
Additionally, immediately after the intervention
approximately 60% of the participants of the educa-
tion group perceived a clinically important improve-
ment in pain intensity and functional disability
compared to a percentage of approximately 40% in
544 Clinical Rehabilitation 29(6)
the control group. At 3 months follow-up the per-
centage of perceived benefit in functional disability
increased to 72%, with statistically significant dif-
ferences compared with the control group.
Previous studies have shown that (exercise and
specifically) aquatic exercise, or pain neurophysi-
ology education, in isolation, are effective in reduc-
ing pain and disability,9,10,19 and that the
combination of both interventions revealed no
additional benefits.19,33 In contrast with those stud-
ies, this study’s findings showed that the addition
of a pain neurophysiology education component
before undertaking the aquatic exercise pro-
gramme, proved statistically and clinically impor-
tant benefits in reducing pain and functional
disability at 3 months follow-up.
The reason why the education group had better
medium term outcomes in this study is unclear.
However, it is hypothesised that these outcomes
may be related to the pain neurophysiology educa-
tion component, which was introduced to change
maladaptive pain cognitions, illness perceptions or
coping strategies, to further introduce normal
movement and activity.18.20
Previous studies have found a positive and
strong relationship between changes in maladap-
tive pain beliefs (r = 0.88, P< 0.01) and the patient’s
ability to perform physical tasks, such as, forward
bending or the straight leg raising test.34 Other
research studies have also shown that pain recon-
ceptualization reduces pressure pain threshold,35
pain catastrophizing,34,36 and modifies maladaptive
pain beliefs about the origin of pain.13,37,38
Those studies’ findings have also suggested that
a better understanding of the pain condition could
not only contribute to change maladaptive pain cog-
nitions, but could also improve the patients’ percep-
tion of their ability to control and manage pain.39 In
this study, the topics introduced in the pain neuro-
physiology education sessions such as, the flare-up
management and pacing strategies, together with
the new perspective that 'pain is different of injury',
may have helped the participants to decrease the
threat, thus reducing the perception of pain inten-
sity,40,41 becoming progressively more able to cope
with pain and achieve long lasting outcomes when
compared with the control group. Although the
findings of this study were only concerned with
short-term outcomes, previous studies that have
evaluated the effects of pain neurophysiology edu-
cation in the medium and long-term showed that
improvements in pain intensity and function remain
at least until the 1-year follow-up.20,42
Despite the non-statistical differences between
groups it is worth to notice the increased propor-
tion of participants in the education group that per-
ceived a benefit in their functional capability
(improved above the minimal clinically important
difference) and the statistical differences found
between groups 3 months after the finishing of the
program when this (the perceived benefit) criterion
was taken in account.
Additionally, the non-statistically significant
differences found between groups in kinesiophobia
were also highlighted as important findings from
this study. Although these findings are consistent
with previous studies,19 it was expected a signifi-
cant decrease in kinesiophobia in the participants
in the education group. This suggest that the effects
of the pain neurophysiology education could be
more related with changes in pain intensity medi-
ated by other cognitive factors, such as functional
self-efficacy or catastrophizing, then with pain
related fear.11,43 Previous studies have shown that
when self-efficacy is high, elevated pain related
fear might not lead to increased pain and disabil-
ity.11 Moreover, higher catastrophizing and lower
functional self-efficacy are the unique factors
related to greater pain intensity on chronic low
back pain patients.11 An improvement on func-
tional self-efficacy and a decrease on catastrophiz-
ing may result in increased activity levels, which
may lead to increased pain thresholds and pain tol-
erance in the longer term.35
There are a number of potential limitations in
this study. Firstly, the small sample size used, the
limited base of recruitment (only in one outpatient
clinic) and the participants’ clinical characteristics
(low levels of functional disability and kinesiopho-
bia)30,44-46 may differ from other chronic low back
pain patients. Moreover, the physiotherapists
involved in the intervention (aquatic exercise and
pain neurophysiology education) were not blinded
to group assignment. Both circumstances may
decrease the external validity of this study’s
findings.
Pires et al. 545
Secondly, the attitudes and beliefs of the physi-
otherapists concerning chronic low back pain were
not controlled. There is evidence in the literature
for a relationship between the beliefs and attitudes
of physiotherapists, the information transmitted to
patients and their maladaptive beliefs.47,48 However,
there were strict instructions to the physiotherapist
to guarantee a similar interaction with both groups
and to follow the protocol designed for the aquatic
exercise intervention.
Lastly, participant’s knowledge about pain
neurophysiology was not controlled. This inves-
tigation was based on the assumption that the
pain neurophysiology education sessions pro-
vided appropriate information to change partici-
pant’s maladaptive pain cognitions, illness
perceptions or coping strategies. Although previ-
ous studies have shown that face-to-face pain
education (individual or in group) is effective in
altering pain beliefs,34,42 in this study, this was
not formally assessed.
In conclusion, this study indicates that the pro-
vision of pain neurophysiology education is a
clinically effective addition to aquatic exercise.
Further studies are necessary to better understand
how pain neurophysiology education influences
pain intensity and disability and to evaluate the
long terms effects of this intervention on pain and
disability.
Clinical messages
•• Providing education on the neurophysiol-
ogy of pain before a six-week course of
aquatic exercise led to a greater improve-
ment in pain intensity 3 months after the
intervention, when compared with aquatic
therapy alone.
•• A greater proportion of participants in the
education group, perceived treatment
benefits at the 6 weeks post-intervention
and at the 3 months follow-up.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any fund-
ing agency in the public, commercial, or not-for-profit
sectors.
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