Neighborhood walkability moderates the association between low back pain and physical activity: A co-twin control study

•Walkability moderates the association between low back pain and physical activity.•Genetics and shared environmental factors do not appear to affect this relationship.•People with low back pain are less likely to benefit from a walkable environment.

The aim of this study was to investigate whether neighborhood walkability moderates the association between low back pain (LBP) and physical activity (PA), using a co-twin design to control for genetics and shared environmental factors. A cross-sectional analysis was performed on 10,228 twins from the Washington State Twin Registry with available data on LBP from recruitment surveys between 2009 and 2013. LBP within the past 3 months was our exposure variable. Our outcome variables were sufficient moderate or vigorous-intensity PA (MVPA, defined as at least 75 min of vigorous-intensity PA, or 150 min of moderate-intensity PA per week), and walking (≥ 150 min per week). Neighborhood walkability, estimated using the commercially available Walk Score®, was our moderator variable. After controlling for the influence of genetics and shared environment, individuals reporting LBP were significantly less likely to engage in sufficient MVPA if they lived in a neighborhood with high walkability (OR = 0.59, 95%CI: 0.36-0.96). There was no association between LBP and sufficient MVPA for individuals living in a neighborhood with low walkability (OR = 1.27, 95%CI: 0.93-1.72), demonstrating that walkability is a significant moderator of the association between LBP and PA (interaction p = 0.013). These findings were similar for the association between LBP and walking (high walkability OR = 0.42, 95%CI: 0.22-0.78; low walkability OR = 0.71, 95%CI: 0.46-1.12), although the interaction was not significant (p = 0.700). Neighborhood walkability moderates the association between LBP and PA. Our results highlight the importance of targeting interventions promoting PA towards individuals with LBP living in a neighborhood with good walkable access to amenities.