#170 Back to activity: When is exercise effective for back pain?
CLINICAL QUESTION
Is exercise effective for non-specific lower back pain and, if so, when and which exercises?
BOTTOM LINE
For acute back pain, exercise does not improve pain, but giving advice to stay active (versus rest) will improve function slightly and reduce sick days (by ~3 days). For chronic back pain, exercise is effective, reducing pain 10-13 points (out of 100), and preventing pain recurrence for one in four patients/year. Exercise (probably strength and stability with physiotherapy) is likely better than medicines and should be recommended to all patients.
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EVIDENCE
- Systematic reviews of randomized controlled trials (RCTs). All scales out of 100.
- Acute back pain (<6 weeks):
- Advice to stay active versus bed-rest (four RCTs) improved function six points and reduced sick leave (mean 3.4 days).1
- Adding exercise to advice to stay active gave no benefit.2
- Exercise not effective for pain or function.3
- Others report similar findings.4-6
- Advice to stay active versus bed-rest (four RCTs) improved function six points and reduced sick leave (mean 3.4 days).1
- Chronic back pain (>12 weeks): Exercise effective.3,5,7-9
- Motor control exercises (strength and stability, often via physiotherapy)9 versus no intervention reduces pain 10-13 points.
- Others report similar findings. 3,5,7
- Exercise also reduces:
- Recurrent back pain episodes by about 50%, with Number Needed to Treat (NNT)=4 over ½-2 years.10
- Others11 report NNT=8.
- Use of sick-leave, NNT=6 over one year.11
- Others find similar.12,13
- Recurrent back pain episodes by about 50%, with Number Needed to Treat (NNT)=4 over ½-2 years.10
- Motor control exercises (strength and stability, often via physiotherapy)9 versus no intervention reduces pain 10-13 points.
- Types of exercise:
- Some report that motor control exercises are better than other exercises,7-9 but the differences are likely clinically irrelevant or small (pain ~4-8 points).7,9
- Others report:
- Aerobic activity (like running or walking) effective.14
- Other studies similar but strength of evidence for walking is low.15,16
- Pilates reduces chronic pain ~14 points versus advice to do normal activities or similar but is not better than other activity.17
- Others studies inconsistent.18
- Aerobic activity (like running or walking) effective.14
- Limits: Studies were often inconsistent, making pooling and definitive conclusions difficult.2,4 Some studies use reporting methods that have little clinical relevance.8,13,14
- NSAIDs19 and strong opioids20 reduce chronic back pain ~3-9 points, which is typically less than that seen with exercise.
- Guidelines for both acute and chronic back pain recommend remaining active and exercise.21
- Some research suggested supervisor programs or self-management programs may improve adherence.22
- More exercise sessions improves the effect.23
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