Exercise and non-specific low back pain

Non-specific lower back pain is a common condition that results in significant impact on a person’s function and quality of life. Therefore it is important to identify management strategies that:

  • Decrease the pain
  • Restore mobility
  • Hasten recovery so individuals can resume normal daily activities as soon as possible
  • Restore and preserve physical independence, comfort and emotional wellness.

Regular exercise has been put forward as one such strategy.

Non-specific lower back pain (NSLBP) is pain not attributed to a recognisable abnormality or malfunction (e.g. infection, tumour, osteoporosis, rheumatoid arthritis, fracture, inflammation).

NSLBP is second only to the common cold as the most common affliction: 84% of people are likely to experience NSLBP during their lifetime, with approximately 12% of the population experiencing intense pain that causes disability, i.e. they are unable to perform daily tasks. 44%-78% people suffer a relapses after an initial episode of NSLBP where the pain reoccurs and 26%-37% of such relapses result in the individual being absent from work.

Whilst there are many different causes of lower back pain (see previous articles: “Understanding and avoiding back pain and stress as the cause of back pain”) in 85% of cases there is no obvious cause of NSLPB.

Additionally, the large number of work days lost poses an economic burden on society. A substantial proportion of individuals with chronic NSLBP also have chronic widespread pain and other pain manifestations such as headaches, abdominal pain and pain in different locations of the extremities. This means that there is also a significant impact on the emotional wellness of the community.

Until relatively recently, those experiencing NSLBP were advised by medical practitioners to rest and avoid physical activity. "However, there is convincing evidence of the harmful effect of bed rest, which was long recommended for acute low back pain." [Y. Henchoz, A. Kai-Lik So / Joint Bone Spine 75 (2008) 533e539.]

Since 2007, several studies have concluded that exercise is a viable treatment for NSLBP and rather than resting.. Indeed, individuals suffering from NSLBP should participate in regular exercise. Participating in an exercise regime goes beyond just being physically active: "Exercise was defined by the International Paris Task Force as a series of movements specifically designed to condition or develop the body when performed regularly or to improve fitness as a means of promoting health." [Abenhaim L, Rossignol M, Valat JP, 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.
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Generally, exercise is important for overall wellness. The benefits gained from exercising regularly are particularly helpful in the treatment and management of NSLBP. Exercise leads to stronger, more toned muscles, which provide more stability for your back.

Endorphins released during exercise reduce stress and provide a natural high, which are particularly helpful in counteracting negative feelings that can be triggered by being in constant pain.

Different characteristics of exercise programs have been explored to determine which are of particular importance in the management of NSLBP. Namely:

  • General versus specific exercises
  • Group versus one-on-one exercise programs
  • Supervised versus home exercise
  • Muscle strengthening
  • Cardiovascular endurance
  • Stretching

General versus specific exercises

pecific exercises focused on stabilising the trunk, compared to general exercises (those that promote overall fitness and well being) weren’t shown to be more beneficial in the longer term.

The conclusion being that exercise, whether specific or general, is good for NSLBP, and more studies need to be carried out in order to determine if either has a significant advantage.

"Compared to general exercise, retraining specific trunk muscles using ultrasound feedback was significantly better in terms of short-term function and perception of effect." [Ferreira ML, Ferreira PH, Latimer J, et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: a randomised trial. Pain 2007;131:31e7.]

Group versus one-on-one exercise programs

Where it is possible to tailor both the amount of exercise and the intensity of the exercise program to the individual, some research has shown "that individually designed exercise programs were more effective than standard programs." [Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. An Intern Med 2005;142:776e85.]


Other research identified some benefits from group exercise classes. This is because some people find the supportive nature of groups emotionally beneficial and motivational, which encourages both participation and adherence.

Supervised versus home exercise

Strong evidence is available that supervision significantly improves the effectiveness of exercise programs. [Moffett JK, Torgerson D, Bell-Syer S, et al. Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences. BMJ 1999;319:279e83.)]

Supervision tends to lead to more adherence to the program and better execution of exercises as professional support is on hand to provide expert guidance on how to use equipment; what intensity to exercise at and correcting poor posture. On the other hand, exercising at home provides more flexibility for some people who lead very busy lives and find it difficult to attend formal exercise sessions.

Personal exercise equipment can help with form by providing more control over the range of motion and way in which the exercise is performed. Feedback from smart consoles, like the UNITY cardio console used on Technogym equipment, can provide encouragement and motivation through individual goal setting.

Muscle strengthening

Having strong core muscles is critical to decreasing the stresses placed upon the lower back and pelvis. The American College of Sports Medicine (ACSM) recommends doing muscle-strengthening exercises a minimum of two times per week. It is also important to take a few days off per week from strengthening exercises to allow the body to rest and build strong muscles.

Evidence suggests that emphasis should be put on endurance rather than on maximum force in patients with low back pain. This means that exercises should be performed with between 10-15 repetitions per set, rather than the 8-10 normally indicated for strength training. [McGill SM. Low back exercises: evidence for improving exercise regimens. Phys Ther 1998;78:754e65.)]

The Pure Strength Lower Back Bench is ideal for strengthening lower back muscles. Fully adjustable, it enables the user to select their most comfortable exercise position; there are 9 different pad positions plus a wide footplate for exercise variations.

Cardiovascular endurance

The ACSM also recommends that patients with low back pain improve their aerobic performance by performing exercises that promote cardiovascular endurance. That is exercising at 60% of your maximum heart rate for 20 minutes a day.

The ACSM advises undertaking functional exercises such as brisk walking, swimming and avoiding high impact exercises such as running, which can in some circumstances exacerbate NSLBP. (Please see related article for more details about suitable exercises for building cardiovascular endurance: "Which physical activities and sports can be recommended to chronic lower back pain patients after rehab.")

Stretching

The spinal column and the muscles, ligaments and tendons that surround it are all designed to move. Consequently, if tight muscles limit this motion it can make back pain worse. Almost everyone can benefit from stretching the muscles, ligaments and tendons in the back, legs, buttock, and around the spine.

The ACSM cautions against performing stretching exercises that exacerbate the pain and recommends stretching 2-3 times a week with 3 reps for each muscle group using both static and ballistic stretches. [Simmonds MJ, Dreisinger TE. Lower back pain syndrome. In: ACSM’s exercise management for persons with chronic diseases and disabilities. 2nd ed. Champaign, IL: Human Kinetics; 2003. p. 217e21.)]