Exercise for Low Back Pain

prevention and treatment

Dr. Pardis Noormohammadpour
Assistant Professor of Sports and Exercise Medicine
Tehran University of Medical Sciences

Introduction
In US, low back pain has first rank between
thirty diseases contributing to years lived with
disability in 2010.

Murray CJ, Abraham J, Ali MK et al. The State of US Health, 1990-2010: Burden of
Diseases, Injuries, and Risk Factors. JAMA 2013.

 Point prevalence and one year prevalence of low

back pain in general population has been
estimated between 1.0% to 58.1%, and 0.8% to
82.5%, respectively, based on a systematic review
throughout the world.
Furthermore, one year recurrence range has
been estimated from 24% to 80%.

Hoy D, Brooks P, Blyth F et al. The Epidemiology of low back pain. Best Pract Res
Clin Rheumatol 2010;24(6):769-81

 The point prevalence of LBP in this survey was

35.9%.
Prevalence of LBP during Last year was 18.6%.

(Urban HEART) in Tehran, 2011

LBP duration
Acute (pain for up to 7 weeks)
Subacute (pain for between 7 and 12 weeks)
Chronic (>12 weeks)

Institute for Clinical Systems Improvement (ICSI); 2012 Jan

The aim of the recommended

treatments
To reduce the pain
To improve function

Exercise for acute low back pain

Activity modification and bed rest:
Multiple randomized trials have now
demonstrated that recovery from pain is equally
rapid and complete without bed rest.
patients advised to rest in bed may even have
slightly more pain and less functional recovery
than those advised to remain ambulatory.
Advice to rest in bed versus advice to stay active for acute low-back pain and
sciatica.
Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB
Cochrane Database Syst Rev. 2010;

 Randomized trials also suggest there is no

advantage to bed rest for patients with
sciatica.

Lack of effectiveness of bed rest for sciatica.

Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knottnerus JA
N Engl J Med. 1999;340(6):418.

 Bed rest should be avoided if possible.

Exercises directed by a physical therapist, such
as the McKenzie method and spine
stabilization exercises, may decrease recurrent
pain and need for health care services.
Am Fam Physician. 2012 Feb 15;85(4):343-50.
Diagnosis and treatment of acute low back pain.
Casazza BA.

 Patients should be told that they are not

fragile, and that rapid return to normal
activities of daily living is generally the best
activity recommendation.

The treatment of acute low back pain--bed rest, exercises, or ordinary activity?
Malmivaara A, Hkkinen U, Aro T, Heinrichs ML, Koskenniemi L, Kuosma E, Lappi S,
Paloheimo R, Servo C, Vaaranen V
N Engl J Med. 1995;332(6):351

 Patients should be encouraged to walk and

resume normal daily activities as quickly as
possible.

Exercise-based therapy for low back pain, Steven J Atlas, MD, MPH
last updated: Sep 26, 2013

 For patients with acute, work-related low back

pain, the use of a classification-based
approach resulted in improved disability and
return to work status after 4 weeks, as
compared with therapy based on clinical
practice guidelines.
Comparison of classification-based physical therapy with therapy based on clinical
practice guidelines for patients with acute low back pain: a randomized clinical
trial.
Fritz JM, Delitto A, Erhard RE
Spine (Phila Pa 1976). 2003;28(13):1363

 There is modest evidence that patients at high

risk of developing chronic pain may benefit
from early psychologically-informed physical
therapy.

Relationship between categorization with the STarT Back Screening Tool and
prognosis for people receiving physical therapy for low back pain.
Fritz JM, Beneciuk JM, George SZ
Phys Ther. 2011 May;91(5):722-32. Epub 2011 Mar 30

 In particular, exercise regimens matched to the

patient's source of pain or directed at specific
biomechanical impairments are likely to yield
greater pain relief.
Further trials are needed to assess the benefits of
individualized exercise therapy for acute LBP.
Does it matter which exercise? A randomized control trial of exercise for low back
pain.
Long A, Donelson R, Fung T
Spine (Phila Pa 1976). 2004;29(23):2593.

Exercise for subacute and chronic LBP

Exercise therapy has been shown to have
modest benefits in patients with subacute and
chronic LBP.

Exercise therapy for treatment of non-specific low back pain.

Hayden JA, van Tulder MW, Malmivaara A, Koes BW
Cochrane Database Syst Rev. 2005;

 Exercise therapy improves short-term pain

relief and function in patients with chronic
LBP.
Exercise can lessen the behavioral, cognitive,
affect and disability aspects of back pain
syndromes.
Exercise as a treatment for chronic low back pain.
Rainville J, Hartigan C, Martinez E, Limke J, Jouve C, Finno M
Spine J. 2004;4(1):106

 The improvements associated with exercise

therapy may be long lasting (1-3 years).

Exercise therapy for chronic nonspecific low-back pain.

van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder
MW
Best Pract Res Clin Rheumatol. 2010;24(2):193.

 In both subacute and chronic LBP, exercise

therapy is particularly beneficial when the
exercise approach includes aerobic activity and is
accompanied by biopsychosocial based
approaches that include cognitive behavioral
strategies facilitating a graded exercise regimen
(ie, increasing exercise activity in small steps)
Exercise-based therapy for low back pain, Steven J Atlas, MD, MPH
last updated: Sep 26, 2013

 Exercise therapy that consists of individually

designed programs, including stretching or
strengthening, and is delivered with
supervision may improve pain and function in
chronic nonspecific low back pain.
Systematic review: strategies for using exercise therapy to improve outcomes in
chronic low back pain.
Hayden JA, van Tulder MW, Tomlinson G
Ann Intern Med. 2005;142(9):776.

 A meta-regression analysis found the best outcomes

for exercise therapy incorporated all of the following
elements:
Individualized regimens
Supervision
Stretching
Strengthening
Systematic review: strategies for using exercise therapy to improve outcomes in
chronic low back pain.
Hayden JA, van Tulder MW, Tomlinson G
Ann Intern Med. 2005;142(9):776

Timing and dosage of exercise

Dosing aerobic exercise and Specific exercise
programs (eg, strengthening, core stability, )
should follow established guidelines, including
a gradual increase based on individual
conditions.
Exercise-based therapy for low back pain, Steven J Atlas, MD, MPH
last updated: Sep 26, 2013

Multidisciplinary rehabilitation
These programs combine graded exercise therapy
with a psychosocial approach.
A systematic review found multidisciplinary
rehabilitation with a workplace visit more
effective than usual care for subacute LBP,
alleviating subjective disability, and resulting in
quicker return to work.
Multidisciplinary biopsychosocial rehabilitation for subacute low back pain among
working age adults.
Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B
Cochrane Database Syst Rev. 2003

Disease specific approach

Lumbar spinal stenosis:
Non-surgical treatment, including exercise
therapy, is the mainstay of conservative
management for LSS.

Exercise-based therapy for low back pain, Steven J Atlas, MD, MPH
last updated: Sep 26, 2013

 Lumbosacral radiculopathies:
In a randomized trial in patients with severe
radicular pain, patients assigned to active
treatment with symptom-guided exercises
showed more clinically-important improvement
in functional status and pain compared to
patients assigned to a program with sham
exercises.
The efficacy of systematic active conservative treatment for patients with severe
sciatica: a single-blind, randomized, clinical, controlled trial.
Albert HB, Manniche C
Spine (Phila Pa 1976). 2012;37(7):531.

 Following lumbar disc surgery :

In a systematic review of 13 randomized trials,
there was strong evidence of efficacy for
intensive exercise programs starting four to six
weeks postoperatively and no evidence that
they increase the reoperation rate .
Rehabilitation following first-time lumbar disc surgery: a systematic review within
the framework of the cochrane collaboration.
Ostelo RW, de Vet HC, Waddell G, Kerckhoffs MR, Leffers P, van Tulder M
Spine (Phila Pa 1976). 2003;28(3):209.

 Spondylolysis and spondylolisthesis:

A systematic review of two randomized trials
found that a specific exercise intervention, alone
or in combination with other treatments,
improved pain symptoms in patients with
spondylolysis or spondylolisthesis
A systematic review of physiotherapy for spondylolysis and spondylolisthesis.
McNeely ML, Torrance G, Magee DJ
Man Ther. 2003;8(2):80.

Who prescribe exercise?

It is important that the treating clinician encourages early
activation of the patient(aerobic, early return to normal
activities).
All patients need some level of oversight when performing
an exercise regimen with which they have no prior
experience.
As discussed above, the most appropriate therapy is
individualized to the patient's symptoms and response to
specific exercises.
Exercise-based therapy for low back pain, Steven J Atlas, MD, MPH
last updated: Sep 26, 2013

Prevention of LBP
The European Guidelines for Prevention in
Low Back Pain suggest that primary
prevention of LBP is feasible and effective.

How to prevent low back pain.

Burton AK, BalaguF, Cardon G, Eriksen HR, Henrotin Y, Lahad A, Leclerc A, Mller
G, van der Beek AJ, COST B13 Working Group on European Guidelines for
Prevention in Low Back Pain
Best Pract Res Clin Rheumatol. 2005;19(4):541.

 Many believe exercise therapy might have a

role in secondary prevention, particularly for
those predisposed to having recurrent LBP.
The most promising approaches seem to
involve back flexibility and strengthening
exercises.
Exercises for prevention of recurrences of low-back pain.
Choi BK, Verbeek JH, Tam WW, Jiang JY
Cochrane Database Syst Rev. 2010;


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