Exercise for nonspecific low back pain
Exercise is safe for most patients with nonspecific low back pain. Graded exercise programs can assist in recovery by improving physical function and normalising central nervous system activity (which is often altered in people who experience chronic pain). There is moderate-certainty evidence that formal exercise therapy probably improves pain compared with no treatment, usual care or placebo; although any improvement in function may be smallHayden, 2021. However, encouraging patients to exercise also reinforces positive beliefs about recovery, physical capacity and self-management, and important messages about staying active and resuming usual activities in a graded manner. Maintaining exercise after the resolution of an acute episode of nonspecific low back pain may reduce the frequency of recurrent episodes.
Many different exercise programs have been advocated for the treatment of nonspecific low back pain, including exercises in a specific direction (direction-biased exercise programs, such as flexion or extension), exercises to strengthen the trunk stabilising muscles, and exercises to improve flexibility or enhance aerobic fitness. Given the wide range of potentially appropriate exercise modes and dosages, it is difficult to draw definite conclusions about the comparative effectiveness of specific programs. Data suggest Pilates exercises, and exercise that promotes whole-body, compound movements (eg squats, lunges, step-ups) and is functionally oriented, may be more beneficial than nonfunctional exercise (eg specific stabilising exercises)Hayden, 2021. Furthermore, isolated nonfunctional exercise may reinforce misconceptions about the nature of the pain and promote fear-avoidance behaviour in the longer term. High doses of exercise treatments are likely more beneficial in improving pain and function compared with low doses.
In this context, a pragmatic approach to exercise for nonspecific low back pain is recommended based on the practice points in Practice points for recommending exercise for patients with nonspecific low back pain. Appropriately guided exercise programs can be undertaken independently, in a group, or as part of an existing fitness program. Consider referral to a physiotherapist particularly for patients with risk factors for poor prognosis. In the short term, some patients may require specific movement re-education or exercise based on their clinical presentation (eg severity of pain, anxiety related to pain). This approach may also be needed for patients who do not recover within a clinically reasonable time frame.
Oral analgesia may be required to facilitate exercise (see Pharmacological management of nonspecific low back pain).
- Emphasise to the patient that it is safe and helpful to move. Bracing and avoiding normal movements is unhelpful in the long term. Using phrases like ‘hurt does not mean harm’, ‘sore but safe’, and ‘your spine is strong’ may be helpful. Some patients may benefit from individualised education about their beliefs, fears and pain experience.
- Exercise programs should be individualised, taking into account the patient’s physical activity preferences, beliefs and specific functional impairments.
- Exercise programs should include stretching, strengthening and aerobic exercises that are functionally oriented.
- Starting with gentle movements is the first step. These might include water-based walking, land-based walking, gentle swimming and floor stretches that encourage the spine to move in its normal planes. Activity should be graded by the duration of time spent exercising, rather than the pain experienced.
- As the patient’s tolerance to activity over longer periods of time increases, the mode, frequency or intensity of activity can be progressed.
- Functional exercises can be introduced to encourage large muscle group activation (eg squats, lunges, step-ups).
- Exercise that patients enjoy (eg yoga, Pilates, walking, cycling) can be gradually introduced (eg start at 15 to 20 minutes’ duration and then increase).
- In the later stages of rehabilitation, more dynamic and higher-load exercises can be performed.