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#170 Back to activity: When is exercise effective for back pain?


CLINICAL QUESTION
QUESTION CLINIQUE
 Is exercise effective for non-specific lower back pain and, if so, when and which exercises?

BOTTOM LINE
RÉSULTAT FINAL
 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
DONNÉES PROBANTES
  • 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  
  • 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 
  • 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
Context:   
  • 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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Author(s)
Auteur(s)
  • Adam Mildenberger BSc MD
  • G. Michael Allan MD CCFP

1. Hilde G, Hagen KB, Jamtvedt G, et al. Cochrane Database Syst Rev. 2002; 2:CD003632.

2. Liddle SD, Gracey JH, Baxter GD. Manual Therapy. 2007; 12:310-27.  

3. Hayden J, van Tulder MW, Malmivaara A, et al. Cochrane Database Syst Rev. 2005; 3:CD000335.

4. van Tulder MW, Koes BW, Bouter LM. Spine. 1997; 22:2128-56.  

5. Chou R, Huffman LH. Ann Intern Med. 2007; 147:492-504.

6. Macedo LG, Saragiotto BT, Yamato TP, et al. Cochrane Database Syst Rev. 2016; 2:CD012085.

7. Byström MG, Rasmussen-Barr E, Grooten WJ. Spine. 2013; 38:E350-8.

8. Searle A, Spink M, Ho A, et al. Clin Rehabil. 2015; 29:1155-67.

9. Saragiotto BT, Maher CG, Yamato TP, et al. Cochrane Database Syst Rev. 2016; 1:CD012004.

10. Choi BK, Verbeek JH, Tam WW, et al. Cochrane Database Syst Rev. 2010; 1:CD006555.

11. Steffens D, Maher CG, Pereira LS, et al. JAMA Intern Med. 2016; 176:199-208.

12. Oesch P, Kool J, Hagen KB, et al. J Rehabil Med. 2010; 42:193-205.

13. Schaafsma FG, Whelan K, van der Beek AJ, et al. Cochrane Database Syst Rev. 2013; 8:CD001822.

14. Meng XG, Yue SW. Am J Phys Med Rehabil. 2015; 94:358-65.

15. Lawford BJ, Walters J, Ferrar K. Clin Rehabil. 2016; 30:523-36.

16. Hendrick P, Te Wake AM, Tikkisetty AS, et al. Eur Spine J. 2010; 19:1613-20.

17. Yamato TP, Maher CG, Saragiotto BT, et al. Cochrane Database Syst Rev. 2015; 7:CD010265.

18. Wells C, Kolt GS, Marshall P, et al. BMC Med Res Methodol. 2013; 13:7.

19. Enthoven WT, Roelofs PD, Deyo RA, et al. Cochrane Database Syst Rev. 2016; 2:CD012087.

20. Chaparro LE, Furlan AD, Deshpande A, et al. Cochrane Database Syst Rev. 2013; 8:CD004959.

21. TOP Guideline: Evidence-Informed Primary Care Management of Low Back Pain. 2015. Available at http://www.topalbertadoctors.org/cpgs/?sid=65&cpg_cats=90. Last accessed: August 26, 2016.

22. Jordan JL, Holden MA, Mason EE, et al. Cochrane Database Syst Rev. 2010; 1:CD005956.

23. Ferreira ML, Smeets RJ, Kamper SJ, et al. Phys Ther. 2010; 90:1383-403.

Authors do not have any conflicts to disclose.