Non-specific low back pain is a major health problem worldwide and is estimated to affect up to 70% of adults.
Exercise therapy has been reported as an effective intervention for the management of chronic low back pain. It can be provided as a supervised program in healthcare settings, group sessions, or as unsupervised home exercise regimens.
While there is an enormous variety of exercise programs available, the current evidence suggests that there is no “ideal” exercise intervention. The many different forms of exercise have shown similar benefits for chronic low back pain. Therefore, exercise programs are probably best chosen according to issues such as patient and clinician preferences, accessibility and costs.
Exercise interventions reported in the literature generally include one or more of the following elements:
• Core or trunk strengthening
• Flexibility and stretching
• Aerobic exercises and functional restoration activities
• Education and incorporation of psychological principles (eg pacing or goal setting)
Episodes of non-specific low back pain that have persisted beyond 12 weeks.
Most (approximately 90%) low back pain is non-specific: the diagnosis of non-specific low back pain implies exclusion of patho-anatomical causes.
Pain relief and improved function are the main benefits from exercise reported in patients with chronic low back pain. Improvements associated with exercise therapy were reported for short (up to six weeks), intermediate (up to 12 months), and long term follow ups (>12 months).
Exercise is contraindicated for patients with any serious medical condition as the cause of the pain (i.e. cancer, fracture, infection, cauda equina syndrome).
The usual precautions and contraindications for exercise also need to be considered (eg falls, injury).
Exercise is considered a safe intervention. However, a minority of people can report mild adverse reactions to exercise (e.g. increased low back soreness, stiff and sore limb muscles). This is often a natural reaction to starting an exercise program for the first time or after a prolonged period of inactivity even in people without low back pain.
All patients need some level of oversight when performing an exercise regimen with which they have no prior experience.
The decision to refer a patient to a physiotherapist, exercise physiologist or other rehabilitation specialist depends upon the presentation of the individual patient (and the capacity to supervise exercise in general practice).
Costs vary significantly depending on the type of exercise. In some cases, health insurance may cover some costs.
The following examples of exercise programs have been shown to be effective for chronic low back pain:
Motor control exercise (or stabilisation exercises)
Motor control exercise aims to retrain the control and coordination of the muscles that support the spine (i.e. deep abdominal muscles, deep spinal muscles, pelvic floor muscles). It was developed based on the rationale that patients with chronic low back pain have altered ability to control the deep trunk muscles (i.e. lack of strength, timing or coordination leading to pain and loss of function).
The intervention initially involves learning how to activate these deep trunk muscles, then progresses to more functional and complex tasks involving the activation of the deep and superficial muscles. It usually requires one-on-one treatment from a physiotherapist and regular monitoring to check you have the right technique.
Motor control exercise has been shown to be effective for reducing pain and function in patients with low back pain, but does not provide any additional benefit when compared to other exercises.
Yoga is an ancient mind-body exercise. Its philosophies, principles and practices were derived from the Vedic tradition of India and the Himalayas. The exercise combines postures and movements, breathing techniques, relaxation and concentration, and meditation (awareness of thoughts). There is a wide-range of styles and schools of yoga; however, there is no clear difference in effectiveness amongst them. Patients should choose a class that suits their fitness level and preferences. Yoga is suitable for anyone, regardless of age or fitness level. It is usually performed in group sessions under the supervision of a qualified instructor.
Yoga has been reported to be effective for reducing pain and back-specific disability in patients with LBP. It is unknown whether it is more or less effective than other types of exercise and medicines.
Pilates is a type of exercise that is similar to other core strengthening programs. It was originally developed to allow injured dancers and athletes to return to exercise, but nowadays it has been adapted as a type of exercise and treatment for conditions such as back pain.
Pilates concentrates on stabilising the core muscles prior to challenging movements, but also on combining breathing and movements, and essentially involves isometric contractions. It mainly focuses on the contraction of the deep muscles of the back and abdominals.
Pilates has been reported to be more effective than minimal intervention (no treatment or advice) for pain and disability outcomes, and for improvement in function and global impression of recovery. Pilates does not seem to be more effective than other types of exercises.
Graded activity exercise
Graded activity exercises were developed based on the rationale that cognitive-behavioural factors play an important role in patients with low back pain. The exercise program aims to reduce pain and disability by addressing physical (eg muscle strength, balance) and psychological (e.g. fear and avoidance, kinesiophobia) components. Other psychological principles can also be used, such as pacing and goal setting. It is usually performed in supervised face-to-face individual sessions with a physiotherapist.
Graded activity exercise can improve pain and disability in patients with chronic low back pain.
Tai Chi is a Chinese mind-body exercise therapy. It is a low-impact activity that involves slow movements, breathing exercises, and meditation. Anyone, regardless of age or fitness level, can practise this activity. Classes are performed by a Tai Chi instructor usually in group sessions, but can be performed individually. A Tai Chi program has been shown to be safe and effective for treating low back pain, with improvements in pain intensity and disability level.
The Alexander Technique involves individualised instructions aiming to improve posture, balance, coordination, and to recognise harmful habits to avoid painful movements (i.e. being aware of muscle overuse when standing, walking and sitting). The Alexander Technique is primarily an educational approach to manage posture and movement, and may improve self-management of back pain. The Alexander Technique requires lessons with a qualified teacher.
There is just one major study that tested the Alexander Technique for low back pain. It reported significant improvements for people who received exercise and lessons in the Alexander Technique. However, more studies are needed to understand better the benefits of this type of treatment.
Home-based exercise programs usually consist of simple strengthening and stretching exercises including walking programs. They have been shown to be effective for reducing pain and disability. However, adherence can be a barrier for the effectiveness of these programs. Home-based programs should be attractive for the patients and supported by health professionals to help facilitate adherence.
TIPS AND CHALLENGES
There is no specific exercise program that can be recommended over another. Patient preferences and response to exercise should be used to determine the type of exercise selected. This also improves patient adherence.
There is no specific dosage of exercise recommended; however, 20 hours of individually supervised sessions over 8 to 12 weeks accompanied by a home program is usually recommended.
The RACGP gratefully acknowledges the contribution of Professor Chris Maher, Tiê Yamato and Bruno Saragiotto, at the George Institute for Global Health at the University of Sydney, in the development of this intervention.
© Royal Australian College of General Practitioners. Originally published in the RACGP’s Handbook of Non-Drug Interventions (HANDI), January2016
References are available at: www.racgp.org.au/handi