Our goal at Ace is to offer the highest quality, fact-checked therapy for anyone seeking help with persistent pain. Long-term lower back pain is one of the regular hindrances that we see in new clients seeking advice. Once we are confident we have ruled out the rare causes of lower back pain such as fractures, inflammatory conditions, infection or malignancy, a moderate part of our recommendations for assisting recovery from back pain, is properly dosed exercise.

On the surface, it is ironic that many governing medical bodies recommended exercise therapy for new and persistent lower back pain. Should we be prescribing exercise or something “stressful” to reduce pain, suffering and disability caused by what might have initially developed after a physically stressful event? A Cochrane review by Hayden et al. (2021) indicates that exercise should be helpful for anyone affected by persistent or recurrent lower back pain to improve pain and function. Cochrane reviews are internationally recognized as the highest standard of evidence-based healthcare free information anyone could seek. Their research reviewing methodologies reduce bias and research errors that is commonly seen across research communication. Their recommendations should not be interpreted dogmatically but can be a trustworthy source to add to your collective interpretation of healthcare evidence. As 249 studies were analysed in this Cochrane review, it is worth summarising.

• Exercise is best defined as “a series of specific movements with the aim of training or developing the body by a routine practice or as physical training to promote good physical health” as defined by Abenhaim, (2000). A specific, regular, progressive exercise routine distinguishes it from other activities undertaken during the day that you might consider active. Exercise types assessed included “muscle strengthening, stretching, core strengthening, flexibility and mobilising exercises, aerobic exercises, functional restoration, McKenzie therapy, and yoga” or called “mixed exercise” when a combination of exercise types was prescribed. 
• Exercise was compared to both no treatment (made up of “usual care and placebo exercise”) and other conservative treatments that are offered for lower back pain including “advice or education alone, manual therapy, electrotherapy, psychological therapy, back school, relaxation, anti‐inflammatory agents or analgesics, or non‐exercise physical therapy interventions.”
• The most common exercise design was “delivered in either a group or individually supervised format, with a median of 12 hours of exercise time delivered over a median of eight weeks.” This is equivalent to three half-hour training sessions per week for eight weeks.
• Outcomes used to determine recovery included pain intensity scales (0-10 scale), questionnaires measuring back specific functional activity limitation and quality of life, perceived recovery, time to return to work and adverse events.
• People with “chronic” lower back pain for greater than 12 weeks were the primary cohort included. Some studies included people reported lower back pain for over 3 years. People with radiating leg pain linked to a primary complaint of back pain were included in the results, such as those diagnosed with lumbar radiculopathy/sciatica or lumbar disc related pathology.
• This review did not include effects of exercise on low back pain caused by specific pathologies including fracture, ankylosing spondylitis, spondyloarthritis, infection, malignancy, pregnancy, or studies that looked at new onset low back pain. However, properly prescribed exercise is still indicated in recovery from all these conditions. If you are experiencing lower back pain from one of these conditions seek advice from an exercise specialist such as an exercise physiologist, or physiotherapist who can provide more than acute care options.

Overall, the review found:

• “Moderate‐certainty evidence that exercise treatment is probably more effective than no treatment, usual care or placebo for pain intensity and functional limitations outcomes”. Unfortunately, we know from other reviews that lower back pain “usual care” is inconsistent with evidence-based clinical practice guidelines, includes the overuse of imaging and opioid prescription and underuse of advice and information (Kamper et al., 2020). Therefore, adding exercise to usual care should be helpful.
• “Low to moderate‐certainty evidence that there is a small difference” or improvement “in pain and functional limitations for exercise treatment compared with other conservative treatments” and exercise treatments “have larger improvements compatible with a clinically important difference” compared to other conservative treatment types.  
• Adverse effects in the 33% of the exercise groups were considered only “minor” and included “increased lower back pain and muscle soreness”. These findings should not cloud the positive findings above as 29% of the comparison groups also reported minor adverse and demonstrate why specialist assistance in finding your individual dosage of exercise is important.
• “The most effective components and approach of exercise treatments for low back pain patients have yet to be confirmed”. This Cochrane review has found no recipes, perfect programs or quick fixes that would be effective for everyone, again indicative that a personalised program, such as you will experience at Ace, is so important.

Overall compared to rest or usual care for lower back pain, exercise appears to be associated with improved recovery, lower long-term healthcare system costs and improvements in disease-free years of life. This review agrees with another large reviewer reporting moderate‐quality evidence of the effectiveness of exercise treatment for persistent low back pain compared to other treatment choices (Skelly et al., 2021). The primary reason why exercise assists with lower back pain and other areas of pain is unknown and is probably dependent on multiple effects, your preferences, and the ability for exercise to be completed consistently within the complexity of your life. We are confident that the reason why exercise is helpful is not dependent on just tissue changes, strengthening or improved movement but also psychological and social factors that facilitate recovery. This is potentially why critical reviews find it difficult to show differences between types of exercise (like aerobic vs resistance vs yoga) for the treatment of pain in general. You can research back pain related exercise-induced analgesia, fear avoidance, cognitive functional therapy if you are curious for more.

Ultimately, 75 to 90% of people with lower back pain or disability fully recover over time, unfortunately just not in 3 days or even 6 weeks much as we might wish that to be true. Assisting you find the right progressive dosage (to minimise adverse events and maximise health effects) and type of exercise to begin with based on your preferences and goals is what we are passionate about at Ace. Hopefully this information is helpful to assist you decide how to return to or/and continue your valued activities when recovering from lower back pain. 

Written by Tom Murphey, DPT.

“Unfortunately for our community, scientific scaremongering is common, easy to believe and hard to heal. Research is often messy, and strong stances or beliefs can be both erroneous and dishonest. I aim to produce honest reviews of some high-quality research to provide informed insight so you can make up your own mind on the science you value.”

References:

Abenhaim L, Rossignol M, Valat JP, Nordin M, Avouac B, Blotman F, et al. The role of activity in the therapeutic management of back pain. Report of the International Paris Task Force on Back Pain. Spine 2000;25(4 Suppl):1S-33S.

Hayden, J. A., Ellis, J., Ogilvie, R., Malmivaara, A., & van Tulder, M. W. (2021). Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews, (9).

Kamper, S. J., Logan, G., Copsey, B., Thompson, J., Machado, G. C., Abdel-Shaheed, C., … & Hall, A. M. (2020). What is usual care for low back pain? A systematic review of health care provided to patients with low back pain in family practice and emergency departments. Pain, 161(4), 694-702.

Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, et al, Agency for Healthcare Research and Quality (US). Noninvasive nonpharmacological treatment for chronic pain: a systematic review update. effectivehealthcare.ahrq.gov/products/nonpharma-treatment-pain/research-2018 (accessed prior to 5 Sept 2021).