Exercise in chronic lower back pain (LBP)

Exercise in chronic lower back pain

• low back pain is defined as pain, muscle tension, or stiffness localised below the costal margin and above the inferior gluteal folds, with or without pain referred to the leg(s) (1)
  • the majority of patients who experience low back pain are labelled as having 'non-specific low back pain', which is defined as symptoms not attributable to a recognisable, known, specific pathology (for example, fracture, ankylosing spondylitis, spondyloarthritis, infection, neoplasm, or metastasis)
  • chronic low back pain
    • chronic lower back pain is defined as pain, muscle tension, or stiffness lasting longer than 12 weeks or recurrent low back pain defined as two episodes in a year, lasting more than 24 hours, with more than 30 days pain-free between
      
      
  • exercise treatment in chronic lower back pain
    • encompasses a diverse set of treatments prescribed or planned by a health professional that include conducting specific activities, postures, or movements (or all)
    • noted that chronic back pain patients in general are less physically active than the majority of the population, meaning most chronic back pain patients come to therapy with very low physical capacities from a lifestyle that is inhibited by the nature of their pain (2)
    • goal of therapeutic intervention is to return patients to the normal activities of daily living - sitting, rising, bending, twisting, lifting, walking, and climbing - by enhancing strength, flexibility, endurance, and balance (2)
    • exercise treatment in chronic lower back pain is characterised by several interacting components:
      • are heterogeneous in
        • treatment design (e.g. standard, individualised),
        • dose (duration, frequency, intensity),
        • delivery format (e.g. clinician supervised, group),
        • specific exercise types (e.g. strengthening, stretching), and
        • may be combined with other conservative treatments
      • examples of exercise treatments include:
        • general physical fitness programmes delivered in a group setting,
        • aerobic exercise in the form of walking programmes, and
        • strengthening of specific muscles or groups of muscles to increase core stability

A systemetic review relating to exercise in chronic lower back pain found (1):

• moderate evidence that exercise probably provides a small benefit for pain outcomes in treatment of chronic low pain compared to no treatment comparisons (including usual care and placebo)
  • observed treatment effect for functional limitations outcomes was small and was not considered clinically important
  • exercise treatment was found to have improved pain and functional limitations outcomes compared to other conservative treatments, however, these effects are small and not considered clinically important
  • not able to make recommendations about specific exercise types based on the results of this review, nor on the work of others to date
  • not able to confirm the safety or harms related to exercise treatment for chronic low back pain; however, the trials that did measure adverse events report few and mostly minor adverse effects, such as muscle pain
• based on available evidence, exercise is likely a good option to manage chronic low back pain. However, when determining if exercise is right for their patient, clinicians can take into consideration a wide range of factors including patient preference, suitability, access, and costs

A network meta-analysis concluded (3)

• review found evidence that Pilates, McKenzie therapy and functional restoration were more effective than other types of exercise treatment for reducing pain intensity and functional limitations
• nevertheless, people with chronic low back pain should be encouraged to perform the exercise that they enjoy to promote adherence

Reference

• Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD009790. DOI: 10.1002/14651858.CD009790.pub2. Accessed 14 June 2023.
• Dreisinger TE. Exercise in the management of chronic back pain. Ochsner J. 2014 Spring;14(1):101-7. PMID: 24688341; PMCID: PMC3963038.
• Hayden JA, Ellis J, Ogilvie R, Stewart SA, Bagg MK, Stanojevic S, Yamato TP, Saragiotto BT. Some types of exercise are more effective than others in people with chronic low back pain: a network meta-analysis. J Physiother. 2021 Oct;67(4):252-262. doi: 10.1016/j.jphys.2021.09.004. Epub 2021 Sep 16. PMID: 34538747