PHYSIOTHERAPY THEORY AND PRACTICE

2018, VOL. 34, NO. 4, 316–328

https://doi.org/10.1080/09593985.2017.1394410

CASE REPORT

Effect of physical therapy management of nonspecific low back pain with

exercise addiction behaviors: A case series
Sudarshan Anandkumar, DPT, M.Sc PT, C-OMPT, CAFS, Cert. (DNT)a, Murugavel Manivasagam, BPT, DYT, COMT,
FSR, DNP, CESb, Vivian Tie Suk Kee, BPhty, MBAb, and Uta Meyding-Lamade, MD, PhDc
a
Registered Physiotherapist, CBI Health Centre, Chilliwack, British Columbia, Canada; bPhysiotherapist, Rehabilitation department – Brunei
Neuroscience Stroke Rehabilitation Centre, Pantai Jerudong specialist centre, Brunei Darussalam; cHead of Brunei Neuroscience Stroke
Rehabilitation Centre, Pantai Jerudong specialist centre, Brunei Darussalam, and Medical director at Krankenhaus Northwest, Germany

ABSTRACT ARTICLE HISTORY

This case series describes two patients, aged 35 and 45 years, respectively, who presented with Received 15 August 2016
chronic nonspecific low back pain (NSLBP) having exercise addiction (EA) behaviors. Diagnosis of Revised 14 January 2017
EA was based on clinical findings, exercising patterns and withdrawal symptoms along with high Accepted 11 February 2017
scores in the EA inventory. This report is a potential first-time description of the successful KEYWORDS
physical therapy management of NSLBP associated with EA utilizing pain neuroscience education Exercise addiction; exercise
(with individualized curriculum), mindfulness, breathing, quota-based reduction in exercises and dependency; behavioral
modification of exercises into social participation, pleasure activities and hobbies. Both the addiction; positive addiction;
patients were seen once a week, for 8 weeks. At discharge, they were pain-free and fully obsessive compulsive
functional, which was maintained at a six-month follow-up. disorder; nonspecific low
back pain; back pain; chronic
pain; pain neuroscience
education

Background Nonspecific low back pain (NSLBP) does not have a

specific cause or pathology and is considered to be
Low back pain is one of the world’s leading musculos-
chronic when the duration is greater than 12 weeks
keletal disorders, being the fifth most common reason
(Verkerk et al., 2011). In clinic practice, patients with
for visiting a physician (Borenstein, 1996). It has a
chronic NSLBP form a complex, heterogeneous group
lifetime prevalence, affecting up to 84% of the popula-
and the occurrence of pain is linked to a variety of
tion (Andersson, 1999; Walker, 2000) and places a
multidimensional factors (Wand and O’Connell,
serious social, occupational and financial burden, with
2008). These may be genetic (e.g. family history of
the combined annual estimates exceeding 90 billion
chronic pain) (Gatchel et al., 2007), physical (e.g. mala-
dollars in the United States (Luo et al., 2004). While
daptive movement strategies) (Martel et al., 2010), psy-
low back pain is self-limiting, with 90% of the popula-
chological (e.g. anxiety and depression) (Bener et al.,
tion recovering with no treatment in three to four
2013), lifestyle (e.g. smoking and sleep disturbances)
months, it has a high recurrence rate of 60% (Gatchel
(Behrend et al., 2012; Kelly et al., 2011), social (e.g.
et al., 1995).
low job satisfaction) (Williams et al., 1998), neurophy-
Low back pain can broadly be classified as either
siological (e.g. central sensitization) (Woolf, 2011) and
nonmechanical or mechanical in nature (Endean
cognitive (e.g. unhelpful thoughts and negative beliefs)
et al., 2011). Few nonmechanical causes for back
(Simons et al., 2014).
pain may include fracture, infection and tumor
Management of NSLBP is multimodal in nature and
(Henschke et al., 2009). Mechanical causes for back
includes pharmacology (e.g. nonsteroidal anti-inflam-
pain include spinal stenosis, spondylolisthesis, spon-
matory drugs), acupuncture, massage, yoga, cognitive-
dylolysis, disc herniation, scoliosis and facet joint
behavioral therapy and physical therapy (Salzberg and
syndrome (Allegri et al, 2016). Although various
Manusov, 2013). Various physical therapy management
causes have been attributed to low back pain, spe-
strategies include therapeutic pain neuroscience educa-
cific diagnosis accounts for only 15% and the
tion (PNE) (Steffens et al., 2016), electrotherapy (e.g.
remaining 85% is nonspecific (Deyo and Phillips,
continuous ultrasound, low-level laser therapy and
1996).

CONTACT Sudarshan Anandkumar [email protected] Registered Physiotherapist, CBI Health Centre, Chilliwack, British Columbia
BC V2R 0M6, Canada
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/gmas.
© 2017 Taylor & Francis
 PHYSIOTHERAPY THEORY AND PRACTICE 317

interferential therapy) (Van Middelkoop et al., 2011), dosage to achieve the same euphoric feeling, leading to
manual therapy (e.g. mobilization, manipulation and dependence behaviors (Hamer and Karageorghis,
soft tissue release) (Van Middelkoop et al., 2011) and 2007). Exercise training also leads to hormonal changes
exercise therapy (Salzberg and Manusov, 2013; Wälti in the body (depressed catecholamines), resulting in
et al., 2015). Exercise therapy has a moderate beneficial reduced arousal of the sympathetic nervous system,
effect on NSLBP and regardless of the type of exercise causing lethargy, mood changes and fatigue (Hamer
(i.e. aerobic, strengthening, stretching and motor con- and Karageorghis, 2007). Therefore, it is hypothesized
trol training), it has a significant effect on work dis- that individuals resort to higher exercise levels to main-
ability (Oesch et al., 2010; Steiger et al., 2012). tain the arousal of the sympathetic nervous system (i.e.
In general, regular exercising has a beneficial effect sympathetic arousal hypothesis) (Thompson and
on the physical, social and psychological well-being, Blanton, 1987).
helping improve the quality of life (Warburton et al., The affect regulation hypothesis presents the idea that
2006). However, indiscriminate use of exercises can running helps reduce distress, anxiety and depression and
result in negative effects, which by itself can lead to improves positive feelings associated with the self
pain, physical injuries and functional limitations (Weinstein and Weinstein, 2014). With exercise depriva-
(Carfagno and Hendrix, 2014). Behaviors of compul- tion, withdrawal symptoms of irritability, guilt, anxiety,
sive, obligatory dependency on physical activity with an fatigue, insomnia and pain have been observed in habitual
inability to suppress the desire to exercise results in runners (Hamer and Karageorghis, 2007). This leads to
excessive exercising and is termed as exercise addiction addiction behaviors in these individuals to avoid the nega-
(EA) (Jee, 2016). Although EA is not currently enlisted tive effects of exercise withdrawal symptoms (Weinstein
in the Diagnostic and Statistical Manual of Mental and Weinstein, 2014). Recently, it has been suggested that
Disorders (DSM-IV), it is recognized as a non-sub- immune transmitters such as cytokines also play an impor-
stance addictive behavior (Lichtenstein et al., 2014). tant role in the development of exercise dependence
Various psychobiological mechanisms have been (Hamer and Karageorghis, 2007). Prolonged exercise trig-
described in the development and sustenance of EA gers the overproduction of interleukin-6, causing an anti-
(Figure 1) (Weinstein and Weinstein, 2014). The inflammatory response and a cytokine sickness behavior
endorphin theory suggests that aerobic exercise stimu- (e.g. increased fatigue, poor concentration and altered
lates the release of various endogenous opioid peptides sleep) (Hamer and Karageorghis, 2007). This prompts indi-
and produces a psychological “high” (Boecker et al., viduals to exercise more to obtain transient relief from these
2008). Prolonged exercising leads to opioid tolerance symptoms, leading to a vicious cycle (Weinstein and
and reduced sensitivity, thus requiring higher exercise Weinstein, 2014).
Apart from the various hypotheses mentioned
above, EA is also associated with individuals who
show excessive concern with their weight and body
image (Landolfi, 2013). Furthermore, EA occurs with
various psychological comorbidities such as obsessive
compulsive disorders and eating disorders (Freimuth
et al., 2011). By trying to gain a sense of body “control”
through exercise, the individual may in turn end up
becoming controlled by exercise (Landolfi, 2013).
According to the cognitive appraisal hypothesis, per-
ceived “healthy methods” like exercise are initially used
to deal with stress. Over time, a conditioned response
occurs where increased exercising is deemed necessary
for a reduction in stress, making it obligatory in nature
(Landolfi, 2013). Overachievers with a perfectionist-
type personality have a higher likelihood of developing
the habits of exercise dependency (Weinstein and
Weinstein, 2014). Few symptoms of EA may include
pain (due to injury), irritability, withdrawal symptoms
of anxiety or guilt when missing an exercise schedule,
Figure 1. Proposed mechanisms in the development and suste- and prioritization of exercise over daily important tasks
nance of exercise addiction (Weinstein and Weinstein, 2014). (Berczik et al., 2012).
318 S. ANANDKUMAR ET AL.

Excessive physical activity lies at the opposite end of

the spectrum involving fear avoidance behavior or
kinesiophobia in chronic pain. Behaviors of fear avoid-
ance result in physical inactivity and muscular insuffi-
ciency, thus sustaining chronic pain (Hasenbring and
Verbunt, 2010). However, according to the avoidance-
endurance model (Hasenbring et al., 2014), positive
mood or attitude, thought suppression and behavioral
persistence in spite of pain can itself lead to physical
overload and muscular overuse, thereby forming an
alternative pathway for chronic pain (Hasenbring and
Verbunt, 2010). This pattern has been shown in sub-
groups of chronic NSLBP (Plaas et al., 2014).
A “U-shaped” association between physical activity
levels and chronic low back pain has been identified,
where individuals undertaking very little or very high
levels of activity may be more likely to have persistent
pain (Heneweer et al., 2009). There is a lack of research
recognizing EA behaviors in chronic NSLBP. The var-
ied mechanisms influencing EA warrants a need for a
holistic approach to address various issues: habits (e.g.
moderation of compulsive exercise routine); maladap-
tive attitudes; beliefs and perception (e.g. education);
coping strategies and self-management skills (e.g.
mindfulness and breathing); and activity modification
to break negative reinforcements from exercise depen-
dency. This report is a potential first-time description
of the successful physical therapy management of EA in
chronic NSLBP using PNE (by adopting a pain curri-
culum), mindfulness, breathing, quota-based reduction
in exercises and activity modification.

Case descriptions
Figure 2. Site of pain (coloured orange) over the lumbar spine
Patient A marked in the body chart as reported by patient A
The first patient in this case series (patient A) was a 35-
year-old male, who presented with complaints of inter-
mittent diffuse pain in his lower back for the past six injuries in the future and avoid his back from
months (Figure 2). The patient noted that his pain “crumbling”.
aggravated when he stopped exercising and completely Once the acute episode of pain subsided, patient A
relieved when he continued his exercise routine. Patient started on a gym exercise program, which he claims to
A worked as an IT professional and reported having a have followed regularly till date to keep his discs “oiled”
sedentary desk job, working 8–10 hours a day, 5 days a and “lubricated”. His workout schedule consisted of run-
week. However, he took frequent breaks in between and ning on the treadmill for 60 minutes and general gym
used a gym ball, dumbbells and elastic resistance bands strengthening exercises (60 minutes), each thrice a week,
during work hours to remain active. He reported a on alternate days. Patient A admitted that he always
previous episode of acute back pain (lasting for a period experienced a “high” when he pushed himself with exer-
of 2 weeks), about 1 year back, which was managed by cises and felt he was in “charge” of his spine. The 24-hour
rest and medications. His general physician diagnosed pattern of symptom behavior was unremarkable and he
him as having a “disc problem” and gave a pamphlet did not have a past medical history of low back pain or
(showing a disc bulge) to read upon. He advised patient surgery. Patient A did not have any disturbances in his
A to start exercising with an aim to prevent similar appetite and bowel or bladder function. However, he
 PHYSIOTHERAPY THEORY AND PRACTICE 319

noted disturbances in his sleep when he missed an exer-

cise session. Coughing did not reproduce the pain and he
had no history of fever, weight loss and malaise. The
patient denied gait disturbances, pins and needles or
numbness down the legs and was not on medications.
Prior laboratory and imaging studies were unremarkable.
On observation, posture and gait analysis revealed no
impairments. On palpation, tenderness was elicited along
his L1–L5 spinous processes; however, it did not repro-
duce his concordant symptoms. Neurological screening
(i.e. reflex, dermatome and myotome testing) did not
reveal impairments and the straight leg raise and slump
test were negative. Range of motion was full and free in
his lumbar spine and no tightness was detected in the
muscle length testing of the quadriceps, hamstrings, hip
flexors and iliotibial band (Norkin and White, 2003).
Muscle strength testing of the gluteal muscles revealed
no abnormalities (Petty, 2013). A supine hooklying
lumbo-pelvic control test was performed with a pressure
biofeedback bag (inflated to 40 mm Hg) placed at the
lumbosacral region (S2 level) (Olson, 2009). The patient
was instructed to perform the abdominal “drawing-in”
maneuver to isolate the transversus abdominis for a 10-
second isometric hold, 10 times. Following this, a heel
slide, a 3-inch march and a bent-knee fallout were per-
formed (Olson, 2009). The patient could maintain an
isolated contraction of the transversus abdominis with
no change in the pressure gauge (Olson, 2009).
Patient A felt his low back pain only on the days he
did not exercise. He admitted sensing a problem with
his exercise regime as he felt tired, sluggish, irritable,
anxious and guilty if he missed his exercise schedule.
He claimed to spend his social life and family time
going to the gym to “avoid” back pain and keep his
back “strong”. Due to this behavior, he sensed a great
Figure 3. Site of pain (coloured orange) over the left lumbar
deal of distress with interpersonal relationships invol-
spine L4-L5 zone marked in the body chart as reported by
ving family, social and work colleagues. He was cur- patient B.
rently seeking a solution to treat as well as prevent back
pain and manage his exercise regime.

beliefs about movement. He sought a second pinion

Patient B with a physiotherapist and was educated on pain biol-
The second patient in this case series (patient B) was a ogy and neuroscience, based on the popular book
45-year-old male, who presented with complaints of “Explain Pain” (Butler and Moseley, 2003). He noted
intermittent pain in his left lower back (L4–L5 zone) significant improvements in his pain and was gradually
(Figure 3). He worked as a manager in an electronics put on a running program and exercises to brace his
store, 8 hours a day, 5 days a week and his occupational abdomen for core strengthening. Although patient B
demands were standing for about 4 hours and desk did not have occurrences of acute back pain since then,
work for the remaining duration. he still noted “aches” and “discomfort” when he
The patient had an acute episode of low back pain stopped running, with complete relief of back pain
5 years back, which was treated with chiropractic with exercising. He claimed to run 5 km everyday to
adjustments. Patient B was initially diagnosed having keep his “core” strong and did not indulge in other
a “weak back” and admitted having fear avoidance hobbies or outdoor physical activities.
320 S. ANANDKUMAR ET AL.

Like patient A, he did not have a past history of surgery, EAI is a valid and reliable tool that helps in identify-
with his imaging and laboratory results being unremark- ing the risk for EA (Mónok et al., 2012) and has a total
able. He denied neurological, bowel and bladder, weight of six questions. EAI is scored on a 5-point Likert scale
loss and sleep disturbances, indicative of a systemic cause. ranging from “1” (strongly disagree) to “5” (strongly
On objective examination, posture, gait, palpation, muscle agree), yielding scores ranging from 6 to 30 (Terry
length, muscle strength and neurological screen were nor- et al., 2004). Scores greater than 24 are considered to
mal. Though patient B did not identify himself as an “exer- be at risk for EA, 13–24 is considered to be sympto-
cise addict”, he felt an obligated need to run to get a “high”, matic and lesser than 12 indicates an asymptomatic
obtain “control of his spine”, maintain the conditioning of individual (Griffiths et al., 2005; Terry et al., 2004). A
his back and brace his “core” muscles with functional baseline score of 28 and 27 was obtained for patient A
activities. At present he mentioned that he felt extremely and patient B, respectively (Figure 4).
depressed on the days he did not run and could visibly see a The NPRS is a reliable tool used to measure pain
change in his “mood” and “energy levels”. For example, intensity where a change of two points is considered
during official work meetings, he kept thinking about run- clinically meaningful (Childs et al., 2005). The patient
ning and felt a constant urge to exercise, move and be rates the least pain, worst pain and average pain over
active. Apart from affecting his pain levels, he sensed the past 24 hours from 0 (no pain) to 10 (worst
anguish at work and was visibly affecting his professional imaginable pain). Patients A and B obtained baseline
life. scores of 6/10 and 5/10 in the NPRS, respectively
(Figure 5).
SF-36 is the most commonly used patient-reported
Outcome measures generic health-related quality of life questionnaire con-
EA Inventory (EAI) (Mónok et al., 2012), Numeric Pain taining 36 items with eight subscales (physical func-
Rating Scale (NPRS) (Childs et al., 2005), Short Form 36 tioning, role limitations due to physical problems,
(SF-36) health survey (Contopoulos-Ioannidis et al., 2009) general health perceptions, vitality, social functioning,
and Global Rating of Change (GROC) scale (Jaeschke role limitations due to emotional problems, general
et al., 1989) were used as outcome measures. Both EAI mental health and health transition) (Ware and
and NPRS were measured at baseline and anticipated to be Sherbourne, 1992). It is a valid and reliable tool, tested
used at the beginning of each treatment session with the in a wide range of populations and the scores range
GROC measured after the first therapy session. SF-36 was from 0 to 100, with higher scores indicating higher
measured at baseline and intended to be used after dis- health (Contopoulos-Ioannidis et al., 2009). The mean
charge from treatment. average of all physically and emotionally relevant items

Figure 4. Graph showing progression of Exercise Addiction Inventory (EAI) scores (Mónok et al, 2012).
 PHYSIOTHERAPY THEORY AND PRACTICE 321

Figure 5. Graph showing progression of Numeric Pain Rating Scale (NPRS) scores (Childs, Piva, and Fritz, 2005).

Table 1. Short form 36 (SF-36) health survey scores at baseline

and discharge for patient A and patient B.
a specific structural cause for back pain. Furthermore,
Patient A scores Patient B scores
normal blood work along with the absence of bowel
At At and bladder disturbances, appetite changes or unex-
SF-36 subscale Baseline discharge Baseline discharge plained weight loss helped in excluding a systemic
Physical functioning 100 100 100 100 cause for the patients’ symptoms.
Role physical 28 100 25 100
Bodily pain 33.6 100 41 100 Results from the EAI along with the subjective history
General health 28.9 97 20 87 and exercising patterns showed that both patients A and B
Vitality 30.1 80 15 75
Social functioning 24.6 75 25 100 were experiencing an addiction to exercise. EAI assesses
Role emotional 23.7 100 0 100 the symptoms of addiction behavior, namely salience
Mental health 20.9 80 12 96
Physical component 43.2 59.8 47.9 56.4 (preoccupation with a particular activity and it starts
summary (PCS) dominating the patient’s thinking, feelings and behavior),
Mental component summary 16.9 51.5 12.5 58.3
(MCS) mood modification, tolerance (increasing the levels of
activity), withdrawal symptoms, conflict (interpersonal
and intra-psychic) and relapse (Griffiths et al., 2005).
was used to establish the Physical Component Work–family relationship strains and withdrawal symp-
Summary (PCS) and Mental Component Summary toms (e.g. anxiety, irritability and changes in energy
(MCS) scores. The PCS and MCS provide a summary levels) were experienced by both patients A and B.
of the physical and emotional quality of life, respec- Furthermore, patterns of exercise obsession were seen in
tively. SF-36 scores for patient A and patient B are both the patients (e.g. patient A using gym ball and
given in Table 1. resistance bands at work; and patient B having the urge
The GROC is a 15-point self-reported outcome mea- to constantly move at work with thoughts of running). In
sure used to gauge the patient’s perceived change of addition, both the patients had a stereotyped pattern of
improvement after treatment has begun (Jaeschke et al., exercising, experienced a “high” (mood modification) and
1989). It has scores ranging from “–7” (a very great deal felt the back pain only when they missed their exercise
worse) to “+7” (a very great deal better), with the schedule.
minimum clinically important difference being three EA is commonly associated with other comorbidities
points (Jaeschke et al., 1989). such as eating disorders (e.g. anorexia) and obsessive
compulsive disorders (Freimuth et al., 2011). Other
addictions that can co-occur with EA include alcohol,
Evaluation and diagnosis
nicotine and illicit drugs (Berczik et al., 2012). Both these
Absence of impairments in objective examination along patients denied any comorbidities, suggesting they did
with normal radiographic findings helped in ruling out not have other addictions as mentioned above. On close
322 S. ANANDKUMAR ET AL.

subjective examination, patients A and B assumed that discussed, with a focus on the multidimensional link
they initially had a problem with the “disc” and “weak between EA behaviors (i.e. obligatory exercising patterns,
core”, respectively (negative beliefs). They still believed maladaptive obsessive thoughts and compromising work–
the current NSLBP to be arising from the same issues family and social life) and withdrawal symptoms (i.e. low
and presumed that exercising kept the discs “lubricated”, energy levels, irritability, anxiety and guilt) with NSLBP.
the core “strong”, maintained the conditioning of the Visual aids by drawing a picture, metaphors, flow charts,
spine and gave a sense of control of the body. Given Windows Microsoft Power Point presentations, various
these clinical findings along with the high scores multimedia videos and animations in Youtube were uti-
obtained in the EAI, it was speculated that the symptoms lized during PNE. Furthermore, specific concerns about
of NSLBP experienced by both the patients were a con- the “disc problem” and “crumbling spine” mentioned by
sequence of a multidimensional interaction between the doctor were addressed (Table 2). Handouts and sum-
maladaptive nociceptive processing and withdrawal maries were given to the patient for reading at home. The
symptoms when they are deprived of exercising. patient version of the neurophysiology of pain test was
given to the patient to be completed one day prior to the
Intervention and outcomes third session (Meeus et al., 2010).
At the beginning of the third session, patient A
Treatment consisted of therapeutic PNE (with individua- noted that his intensity of pain significantly reduced
lized curriculum), mindfulness, breathing, quota-based (Figure 5) with the GROC scores being “–1” (“a tiny
reduction in exercises and modification of exercises into bit worse”). He completed the neurophysiology of
social participation, pleasure activities and hobbies. Both pain test and the results revealed that he had a
patients were seen once a week, for 8 weeks. The treatment good understanding of the PNE sessions. However,
sequence is as given below. the “urge” to exercise still persisted and he noted
feeling a “low” during the day. To manage the symp-
Intervention for patient A toms of withdrawal, after discussing the various treat-
The first two sessions consisted of a one-on-one PNE that ment strategies, he was taught mindfulness training,
lasted about 50 minutes each approximately. The educa- to be practiced for 15 minutes, three times a day
tion content was primarily based on the popular book (Zeidan et al., 2015). He was taught to focus atten-
“Explain Pain” (Butler and Moseley, 2003) and also tion on breathing, instructed to “cuddle his breath”
included an individualized curriculum relating to the or breathe as “soft” as he could, and just “witness”
patients’ main concerns (Table 2). The therapist explained the withdrawal symptoms (including pain) from his
the neurobiology, neurophysiology, origin and processing body in a nonjudgmental manner without affective
of pain from the nervous system (Puentedura and Louw, reaction. The patient maintained a high level of
2012). Furthermore, differences between acute versus adherence to this recommendation. Furthermore,
chronic pain and factors sustaining chronic pain were upon consensual agreement, a quota-based reduction

Table 2. Pain education curriculum adapted to explain main concerns from patient A.
Comments and concerns from patient A Pain neuroscience education (PNE) Aids utilized
“Concerned about the ‘Disc problem’ and Explained about the lack of association between pain Images shown from magnetic resonance imaging
issues of ‘crumbling spine’ mentioned by and “disc issues” seen in imaging (Brinjikji et al., (MRI) demonstrating spontaneous regression
the doctor” 2015). Also, evidence for spontaneous regression of sequestrated discs.
disc herniation shown (Macki et al., 2014).
“If I don’t keep lubricating my discs with Educated on normal time frame for tissue healing. Video of the three tissue-healing phases
exercises, my back is doomed” Though exercise is a positive activity, the effect of (inflammation, repair and remodeling) and
inaccurate thoughts, beliefs, attitudes and functional MRI pictures in brain-related pain
catastrophization leading to NSLBP using the activity were shown
neuromatrix approach was explained (Moseley, 2003)
“If I don’t exercise, I don’t feel in charge of my Importance of perception, self-body-image in relation Various visual and optical illusion pictures shown
spine” to a Neurotag (i.e. interconnection of various parts of to demonstrate the importance of inaccurate
the nervous system to produce a memory or perception in the brain
neurosignature) (Butler and Moseley, 2003) and
evidence for negative body image associated with
increased pain perception presented (Osumi et al.,
2014)
“I feel I need to exercise more to experience a Explained about neurobiological mechanisms of Flow chart utilized (Figure 1)
“high” and relieve my pain. Why do I feel exercise addiction. Further, educated on withdrawal
tired, sluggish and irritable if I don’t symptoms that can occur due to maladaptive coping
exercise?” strategy as a result of excessive exercising (Egorov
and Szabo, 2013)
 PHYSIOTHERAPY THEORY AND PRACTICE 323

Table 3. Quota-based reduction and activity modification of exercise program for patient A.
Pretreatment exercise schedule – Running in the treadmill (60 minutes) and general gym strengthening exercises with the machines (all exercises 15 times
and three sets, taking approximately 60 minutes) every alternate day, 6 times a week. Utilizing gym ball and “extra sets” of strengthening with dumbbells
and resistance bands at work
Treatment Prescription for modifications
sessions Running Machine exercises
3rd week Reduce running to 40 minutes and walk for 20 minutes in the treadmill Reduce exercise dosage to 12 times and 3
reps, thrice a week
4th week Reduce running to 35 minutes and walk for 10 minutes in the treadmill Reduce exercise dosage to 10 times and 3
reps, thrice a week
5th week Change environment of treadmill running to running outside in the park with a friend or Reduce exercise dosage to 8 times and 3 reps,
family (35 minutes) twice a week
6th week Substitute running to playing Frisbee, doing yoga or tai-chi (any one option), 30–40 minutes Reduce exercise dosage to 8 times and 3 reps,
approximately (twice a week) (mode of exercise depending on the choice of patient A) once or twice a week
7th week Continue Frisbee, doing yoga or tai-chi (any one option), 30–40 minutes approximately No strengthening done by the patient as he
(twice a week) (mode of exercise depending on the choice of patient A) did not have the urge to exercise
8th week Continue Frisbee, doing yoga or tai-chi (any one option), 30–40 minutes approximately (once No strengthening done by the patient as he
or twice a week) (mode of exercise depending on the choice of patient A) did not have the urge to exercise

and modification of his exercise regime were carried Outcomes for patient A
out (Table 3). By the eight session, patient A was completely pain free,
In the fifth session, the patient noticed significant felt his life had become “normal”, obtained GROC scores
improvements in all his outcome measures (Figure 4 and of “+7” (“a very great deal better”) and had discontinued
Figure 5). He found the NSLBP to be minimal with mindfulness training. He scored 6 in the EAI, which
improved functioning at work and significantly reduced indicated that he was an asymptomatic individual. At
distress with his interpersonal relationships. He felt the discharge, patient A enjoyed various activities (including
“crave” to exercise had completely disappeared and did yoga, tai-chi, Frisbee, group aerobic and stretching classes
not have feelings of guilt, anger or anxiety when he missed in the gym). A follow-up 6 months later revealed that
an exercise session. His exercising environment was chan- patient A was pain free and completely functional.
ged from running on the treadmill to running outside in the
park with a friend or family. At the beginning of the sixth Intervention for patient B
session, other activities that the patient wanted to explore, The first two sessions consisted of a one-on-one PNE,
such as yoga, tai-chi and playing Frisbee, were substituted which lasted about 30 minutes each approximately.
for running. Though the patient already had PNE from his previous

Table 4. Pain education curriculum adapted to explain main concerns from patient B.
Comments and concerns from patient B Pain Neuroscience Education (PNE) Aids utilized
“My doctor said I have a weak back” Explained that “the spine is one of the strongest A spine model to show how protected the spinal
structures in the body and that very rarely do cord remains within the vertebral canal
people have permanent damage” (Bergmark, 1989).
Further, importance of self-perception of the spine
and relationship between inaccurate body image,
thoughts and beliefs with increased pain explained
(Osumi et al., 2014).
“My physiotherapist said I need to keep bracing Educated on the research regarding effects of Diagram drawn to show how increased
my abdomen to maintain my core strong” persistent pain on back muscles (increased recruitment of core muscles can further
coactivation, earlier onset of “inner unit” core compress the spine, stimulate the pain-sensitive
muscles, as well as inability to relax them) structures and cause persistent pain
(Dankaerts et al., 2009; Geisser et al., 2004; Gubler
et al., 2010). Evidence shown how bracing the
abdomen with functional tasks and running can
actually increase ground reaction forces and sustain
injury (Campbell et al., 2016)
“I was advised that exercise is the only solution to Educated on the normal time frame for tissue Metaphor of a “limp” that persists beyond
my spine problem and that I need to exercise healing. Further, explained how obligatory, normal tissue repair used
regularly every day, failing which I can get my compulsory exercising can become a maladaptive
pain back” behavior, thus by itself sustaining and provoking
NSLBP (Puentedura and Louw, 2012).
“I have the constant urge to move, run and Explained about the effects of exercise addiction Flow chart utilized (Figure 1)
experience the high. Why do I have a change in and withdrawal symptoms, and its intricate link to
my mood, energy levels and experience pain if I maladaptive coping strategies that can sustain pain
don’t exercise?” (Egorov and Szabo, 2013; Landolfi, 2013)
324 S. ANANDKUMAR ET AL.

Table 5. Quota-based reduction and activity modification of exercise program for patient B.
Pretreatment exercise schedule – Running 5 km every day and constant abdomen bracing with functional activities
Treatment sessions Running
3rd week Reduce running to 4 km and walk for 1 km, 5 days a week
4th week Reduce running to 3.5 km and walk for 1.5 km, 4 days a week
5th week Maintain 3.5 km run and 1.5 km walk, however with friends or family, 3 days a week
6th week Progress to 3 km run and 2 km walk with friends or family, 2 days a week; add deep stretching of whole-body muscles
7th week Substitute running with playing badminton, golf or attending dance classes (like zumba), twice a week
8th week Continue playing badminton, golf or dance class (like zumba), once or twice a week

physiotherapist and obtained high scores in the neuro- limitations in its research (Szabo et al., 2015). Most
physiology of pain test (Meeus et al., 2010), he was willing of the outcome measures developed in EA research
to review the content. On both sessions, the PNE curri- such as the EAI (Terry et al., 2004), Obligatory
culum was tailor-made to address his concerns (Table 4). Exercise Questionnaire (Ackard et al., 2002), Exercise
Visual aids by using a spine model, drawing pictures, flow Dependency Scale (Hausenblas and Downs, 2002) and
charts and metaphors were utilized during PNE. Commitment to Exercise Scale (Davis et al., 1993) are
By the third session, patient B noted significant only screening tools, which indicate a susceptibility to
changes in all the outcome measures (Figure 4 and dysfunction (Berczik et al., 2012). They do not have a
Figure 5) with GROC scores of “3” (“somewhat better”). diagnostic value as no tool, validated in the clinical
He felt extremely “relieved” and expressed “happiness” population of EA, has been developed to date, suggest-
that he did not have to keep bracing his abdomen for ing a need for further research. The diagnosis of EA
functional activities. However, he still admitted having a along with NSLBP in patients A and B was based on
constant desire to run, experience a “high” to keep his the data obtained from clinical findings, their exercis-
energy levels up and improve his mood, failing which he ing pattern and withdrawal symptoms experienced by
felt anxious during the day. After discussing the various them.
treatment options, in consensual agreement with the From the subjective examination, it was suggested
patient, he was taught diaphragmatic breathing exercise that both patients had maladaptive cognitions regard-
(short 1–2-minute sessions, about 10 times a day) to deal ing their NSLBP. Hence, for this reason, the first two
with anxiety and quota-based reduction and modifica- treatment sessions were dedicated to PNE, with an
tion of his running regime were designed (Table 5). aim to reconceptualize pain, address concerns regard-
ing their back and provide reassurance (Wijma et al.,
Outcomes for patient B 2016) (Table 2 and Table 4). Using anatomical or
At the beginning of the sixth session, the patient had biomechanical models of education for addressing
complete relief of back pain. By the eighth session, he pain and dysfunction has limited efficacy and may
had no limitations, complete absence of withdrawal even have a negative impact on the patients’ outcome
symptoms, reported an excellent quality of life by possibly increasing fear, anxiety and stress
(Table 1) and interpersonal relationships (work and (Moseley, 2004). Furthermore, the choice of words
home) obtaining GROC scores of “+7” (“a very great used by healthcare professionals can significantly
deal better”). A follow-up 6 months later revealed that impact the patient and may potentially worsen their
patient B was pain free and completely functional. negative perceptions with the use of certain terms
(Chooi et al., 2011). The pamphlet (showing a disc
bulge), physician diagnosis of “disc problem” and
Discussion choice of words such as “crumbling” likely increased
This case series describes the successful management the illness perception of patient A. Similarly, for
of two patients with NSLBP having behaviors of EA. patient B, a diagnosis such as “weak back” may
According to the author’s knowledge, this is the first have itself contributed to negative beliefs, leading to
report describing EA in NSLBP. The prevalence of EA the persistence of NSLBP (Tan et al., 2015). This
has a wide variability ranging from 3% to 52% along with an over-emphasis on exercising by the
(Weinstein and Weinstein, 2014). This data is mainly doctor and physical therapist may have directly con-
derived from triathletes, runners, “ultra-marathoners”, tributed to the start of an obligatory pattern of exer-
university sport science students, elite athletes, clients cise ritual seen in both the patients, which over the
in a fitness room and adolescents (Weinstein and period of time led to behaviors of EA.
Weinstein, 2014) and it must be acknowledged that EA can broadly be categorized as primary or second-
there are many methodological and conceptual ary (Landolfi, 2013). In primary EA, the individuals are
 PHYSIOTHERAPY THEORY AND PRACTICE 325

motivated only by the gratification derived from physical gradually introduced in both the patients and consisted
activity whereas in secondary addiction, exercise is used of increasing their social participation (with an aim to
as a means to achieve a secondary objective (such as improve interpersonal relationships) and indulging in
weight loss) (Landolfi, 2013). It has been suggested that activities they found pleasurable (such as yoga, tai-chi
the objectives for engaging in exercising forms an impor- and a dance class) (Table 3 and Table 5). The authors
tant factor in developing EA (Hamer and Karageorghis, found this to be important to break the patients’ struc-
2007) and it is clear from this report that both the tured, repetitive “ritualistic” pattern of exercising and
patients engaged in exercises to prevent back pain and stop its prioritization over other responsibilities (at
keep their spine strong. Interestingly, both the patients work and home). It is possible that the varied, fluid
exercised to feel “in charge” or “in control” of their spine and relaxed forms of exercise mentioned above could
and it is likely that when they missed their exercise have influenced the perception of pain by reducing the
sessions, it increased their perception of high vulnerabil- load on sensitive tissues and delinking the triggering
ity to physical stresses (Berczik et al., 2012). This ampli- factors from addictive behaviors (Nijs et al., 2015). It
fies the negative feelings associated with missed sessions must be noted that the graded reduction in exercises
(e.g. stress, anxiety and constant thoughts about mov- and activity modification was not prefixed to fit a
ing), possibly negatively influencing their NSLBP. particular schedule at the start of the treatment session.
It is interesting to note that though patient B had The whole process was carefully monitored, gradually
detailed pain education based on the popular book evolved over the weeks of intervention with both the
“Explain Pain” (Butler and Moseley, 2003) and patients and was carried out in consensual agreement.
obtained high scores in the neurophysiology of pain Withdrawal symptoms such as anxiety, low energy
test (Meeus et al., 2010), he continued to have inaccu- levels and irritability were experienced by both the
rate thoughts and beliefs regarding his back. This could patients. Furthermore, they also had the urge to exercise
have possibly persisted due to the overemphasis on to experience a “high”, indicating exercise dependency.
“core” exercises by his physical therapist and the gen- This craving to experience a “high” is hypothesized to
eralized pain explanation during his education sessions occur due to the release of beta endorphins and various
(Moseley and Butler, 2015). Reservations have been endogenous opioid peptides, which produce addictive
expressed about the “blanket approach” of explaining behaviors (Hamer and Karageorghis, 2007). They also
pain to patients and the need for an individualized exert analgesic effects (Hamer and Karageorghis, 2007)
curriculum has been suggested to improve outcomes and this could be one plausible reason why both the
(Moseley and Butler, 2015). Communication plays an patients did not experience pain with exercising. To
important part in understanding the biological pro- manage these symptoms, treatment options of mindful-
cesses that are thought to underlie pain (Wijma et al., ness, imagery and breathing were discussed with patients
2016). This helps in changing the patients’ conceptua- A and B. As patient A felt inclined toward mindfulness,
lization of pain and forms a strong foundation upon the same was taught as a treatment strategy for the
which therapeutic interventions can be carried out management of his withdrawal symptoms.
(Nijs et al., 2011). PNE sessions (with a specific curri- Mindfulness-based interventions have shown promising
culum based on the patients’ concerns) helped in clar- results in substance-based addiction disorders (Skanavi
ifying both patients’ misconceptions regarding their et al., 2011). The practice of mindfulness has also been
back pain and withdrawal symptoms experienced found to reduce anxiety and pain (Zeidan et al., 2015,
from EA (Table 2 and Table 4). 2014). Furthermore, due to the nonjudgmental, present-
Quota-based increases in activity and graded expo- centered awareness of the self with a focus on the breath, it
sure forms a part of physical therapy management of is hypothesized to regulate emotions and improve cognitive
patients with fear avoidance (George et al., 2010). EA inhibition, thus helping in self-management (Wimmer
and the constant urge to move lie at the opposite end of et al., 2016; Zeidan et al., 2015, 2014). Patient B was taught
the spectrum involving fear avoidance behavior and diaphragmatic breathing exercise as he was not comfortable
kinesiophobia. Hence, following PNE, a quota-based with imagery or the concept of mindfulness. He felt it had
graded reduction in exercise and activity modification an inclination toward Buddhist practice, going against his
were carried out in agreement with both the patients religious beliefs. Controlled deep breathing has been shown
(Table 3 and Table 5). They were educated on the to be effective in helping with withdrawal symptoms (e.g.
withdrawal symptoms that they would likely encounter irritation and increased tension) of substance abuse such as
during this de-addiciton phase and were given reassur- smoking (McClernon et al., 2004). Hence, diaphragmatic
ance about its management. As they were weaned off breathing exercise was used as a distraction technique
their exercise dosage, activity modification was whenever he experienced distress.
326 S. ANANDKUMAR ET AL.

Although both the patients in this report had NSLBP Conclusion

and EA, the physical therapy management was highly
This report is a potential first-time description of the suc-
individualized. Although EA was initially considered
cessful management of NSLBP along with EA using PNE
erroneously to be positive, it is currently recognized to
(with individualized curriculum), mindfulness, breathing,
have a negative impact on the individual’s life, leading to
quota-based reduction in exercises and modification of
social, work, financial and psychological difficulties
exercises into social activities and hobbies. Although EA is
(Landolfi, 2013). Furthermore, EA by itself can lead to
rare, screening for this concern is important for individuals
physical injuries due to overtraining (Landolfi, 2013).
presenting with musculoskeletal injuries.
The NSLBP experienced by both the patients was specu-
lated to occur due to the maladaptive processing of pain
and the resultant behavior leading to EA was seen to be
Acknowledgments
iatrogenic induced, due to the constant emphasis on
exercise by the respective health-care professionals for The authors thank Megan Sawatsky MPT MCPA for her
patient A and patient B. It is interesting to note that assistance in preparing this manuscript.
although words like “oiling” and “lubricating” the discs
have a positive meaning from a pain science perspective,
inaccurate beliefs or perceptions can lead to NSLBP, as Declaration of interest
seen with patient A. Moreover, overemphasis on “core The authors report no conflicts of interest. The authors alone
exercises” can by itself lead to fear-avoidance beliefs in are responsible for the content and writing of the article.
low back pain (Unsgaard-Tøndel et al., 2013). With
patient B, although he initially claimed to have fear
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