Version August 2024
INTRODUCTION — Low back pain (LBP) is the most common musculoskeletal complaint worldwide, with up to 85 percent of all people experiencing LBP during their lifetimes [1]. Exercise is often recommended to patients with LBP because it reduces pain and helps maintain or restore flexibility, strength, and endurance [2].
LBP is defined as acute (less than four weeks), subacute (4 to 12 weeks), or chronic (more than 12 weeks), according to the duration of symptoms.
This topic will address the rationale and evidence pertaining to exercise in the treatment of nonspecific LBP, which is central or axial pain between T12 and the pelvis that cannot reliably be attributed to a specific disease or spinal pathology [3]. Exercise-based therapy for nonspecific LBP is most appropriate for those with persistent and bothersome symptoms despite self-care management. Those with lumbar radiculopathy and LBP due to spinal stenosis are discussed separately:
●(See "Acute lumbosacral radiculopathy: Treatment and prognosis", section on 'Physical therapy'.)
●(See "Lumbar spinal stenosis: Treatment and prognosis", section on 'Physical therapy'.)
The evaluation of LBP and other treatment modalities for LBP are also discussed separately. As examples:
●(See "Evaluation of low back pain in adults".)
●(See "Treatment of acute low back pain".)
●(See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment".)
●(See "Subacute and chronic low back pain: Nonsurgical interventional treatment".)
●(See "Subacute and chronic low back pain: Surgical treatment".)
ACUTE LOW BACK PAIN — Nonspecific, acute LBP is defined as LBP of less than four weeks duration that cannot reliably be attributed to a specific disease or spinal pathology [3]. The approach to evaluating LBP, including both nonspecific LBP and consideration of specific etiologies, is discussed separately. (See "Evaluation of low back pain in adults".)
While continued activity is encouraged in patients with acute LBP, we do not routinely refer such patients for exercise or physical therapy, as acute LBP (duration of symptoms less than four weeks) is self-limited in most patients [4,5]. Exercise treatment has not been shown to be more beneficial for acute LBP when compared with other acute treatments [6-9]. Therefore, we instead reserve exercise therapy for patients not improved with initial treatment. (See "Treatment of acute low back pain", section on 'Exercise and physical therapy' and "Treatment of acute low back pain", section on 'General approach to care'.)
Patients with acute LBP should be advised to avoid bedrest and stay as active as possible [10]. Patients who wish to exercise may continue to perform their usual exercise regimen or try home-based exercises as tolerated.
SUBACUTE AND CHRONIC LOW BACK PAIN — LBP is defined as subacute (4 to 12 weeks) or chronic (more than 12 weeks) according to the duration of symptoms.
Exercise improves symptoms in subacute and chronic low back pain — We advise exercise or movement-based therapy as a key component of treatment for all patients with subacute and chronic LBP [7,11].
In several systematic reviews of randomized trials, exercise modestly improved pain and function in patients with subacute and chronic LBP [7,8,12,13]. In addition, patients with chronic LBP who regularly participate in moderate to vigorous leisure-time activities have less pain and better function compared with those who are less physically active [14].
The exact mechanism of benefit of exercise in subacute and chronic LBP is uncertain, and several mechanisms are likely to contribute:
●Psychologic – Exercise provides psychologic benefits, including reductions in stress, anxiety, and depression [15-17]. There is a strong association between chronic LBP and depression, and exercise may help to improve the mood of chronic LBP patients, which in turn may lead to an increase in their level of physical activity [18,19]. Some patients are anxious about reinjuring their back and exhibit fear of movement (kinesophobia); exercise can be a means by which these patients learn to confront and overcome their fear [20]. In addition, physical activity interventions can improve the perception of exercise self-efficacy in activity-restricted individuals [21].
●Neurologic – In animal studies, exercise reverses injury-induced neurologic changes in the sensory ganglia, spinal cord, and brain [22-25]. The effects of exercise on pain in animals appear to be generalized; various exercises, even exercise that excludes the injured body part, reduce evidence of pain in the affected region [26].
●Inflammation – Additionally, human studies have found that elevated proinflammatory cytokines and oxidative stress accompany LBP, and exercise attenuates these inflammatory processes [27].
●Musculoskeletal – Exercise has positive effects on human muscle, joint, and intervertebral disc metabolism [28-30]. These tissues require periodic loading in order to maintain their normal metabolism and repair microtrauma. The intervertebral disc does not receive a blood supply and obtains nutrients and metabolism by imbibition (the direct absorption of fluid by the disc), which is optimized by motion and impact.
Counseling and anticipatory guidance — Counseling patients regarding their expectations; addressing patient fears and concerns; and assessing fitness level, interests, and availability of resources are all necessary in formulating an appropriate exercise plan for subacute or chronic LBP. Patients with LBP desire clear and consistent advice from their health care providers regarding treatment options, including self-management as well as information on prognosis and impact on their occupation [31].
Provide motivation — Individuals with neuromusculoskeletal conditions, including LBP, report complex barriers, demotivators, and motivators to performing exercise [32]. Demotivators to exercise include lack of interest, inaccessibility, high cost, self-consciousness, embarrassment, anxiety, frustration, and anger. Motivators to exercise include goal setting and achieving, enjoyment, feeling good and "normal," optimism, self-redefinition, and "escape from everyday boundaries."
Motivational interviewing and motivational enhancement therapy techniques can improve exercise motivation and compliance in patients with chronic LBP [33]. Health coaching for people with LBP with low recovery expectations can result in goal setting and action planning [34]. The use of motivational interviewing for promoting exercise is discussed separately. (See "Exercise for adults: Terminology, patient assessment, and medical clearance", section on 'Assessment of patient willingness to begin exercising'.)
Address patient fears — Educational efforts that address excessive fears about perceived physical vulnerability, pain neurophysiology, and obstacles to exercise and that promote the benefits of exercise can increase physical activities in this population [35-37]. We advise identifying and addressing patient fears by emphasizing the following points:
●Mild discomfort does not indicate an activity should be discontinued – Patients may believe or have previously received advice that certain activities (eg, bending from the waist, twisting, exercise, weightlifting, and other sports activities that stress the spine) are unsafe, particularly if those activities provoke discomfort. Reassurance that a graded return to activity may prompt mild discomfort, along with guidance on when to reduce or discontinue activity (severe or neurologic pain), can be helpful. (See 'Educate about risks and adverse effects' below.)
●Many back "abnormalities" are not contraindications to activity – Patients who have had prior imaging may misunderstand the importance of the anatomic variations that have been identified, such as degenerating, bulging, or herniated discs; facet joint arthritis; ligamentum flavum hypertrophy; spinal stenosis; and hemangiomas. We educate patients that these anatomic findings are not necessarily associated with their pain, do not necessarily require intervention, and can be found in the asymptomatic population [38,39]. Although these anatomic variations may persist, physical activity is not contraindicated, and pain can be well managed and resolve over time.
It may also be helpful to further investigate pre-existing conditions; some patients have been told previously that they have back, hip, or sacroiliac joint "misalignment" or other nonspecific musculoskeletal conditions. In some cases, additional evaluation is necessary to exclude serious etiologies of LBP in which exercise may be contraindicated or may require specialist supervision. The evaluation of LBP, including consideration of serious etiologies (eg, cauda equina syndrome, spinal instability from metastatic disease, etc), is discussed separately. (See "Evaluation of low back pain in adults".)
In the absence of evidence supporting a definitive diagnosis, including compatible medical history, imaging, and/or specialist evaluation, these "diagnoses" are not generally accepted as contributory to symptoms, and patients may be reassured that physical activity is not contraindicated.
Activity recommendations for patients with known spinal stenosis, radiculopathy, or other spinal diagnoses are discussed separately, as patients with these conditions have existing spinal pathology that is distinct from patients with nonspecific LBP. (See "Treatment and prognosis of cervical radiculopathy", section on 'Exercise therapy' and "Lumbar spinal stenosis: Treatment and prognosis", section on 'Physical therapy'.)
●Psychologic and mind-body therapies can be a useful adjunct – Patients with features of central sensitization or nociplastic pain or particularly negative thinking patterns associated with back pain and exercise may benefit from referral for cognitive-behavioral therapy or mindfulness-based stress reduction. These modalities improve back pain and function by addressing psychosocial contributors to pain [40-43]. Further details on nociplastic pain are discussed separately. (See "Evaluation of chronic non-cancer pain in adults", section on 'Nociplastic pain'.)
If available, multidisciplinary rehabilitation programs are effective for patients who need more intensive therapy, including combined exercise and behavioral intervention [44]. Additional details on psychologic and mind-body therapies for subacute and chronic LBP are discussed separately. (See 'Selected exercise modalities' below.)
Educate about risks and adverse effects
●Short-term increase in pain – Among patients with LBP, a temporary exacerbation of symptoms may occur during or after therapeutic exercise. Counseling the patient that there may be an initial exacerbation of symptoms before there is an improvement can be reassuring and reduce kinesiophobia [37]. Increased LBP following exercise is common, usually benign, and simply indicates that the pain-producing tissues have been stimulated.
Overall, when compared with nonexercising control populations, exercise does not appear to increase the risk of LBP exacerbations [2,45].
●Risk of injury – As with any movement-based program, there are risks of injury and other adverse events that may occur with exercise.
Patients may be at risk for musculoskeletal injuries to the hips, knees, and ankles. These and other general risks of exercise are discussed separately. Older or frail patients may be at greater risk of injury due to impaired proprioception and balance as well as osteoporosis and other medical comorbidities. The medical evaluation prior to recommending any exercise program for a patient is also reviewed separately. (See "The benefits and risks of aerobic exercise", section on 'Risks of exercise' and "Exercise for adults: Terminology, patient assessment, and medical clearance", section on 'Medical assessment and clearance for exercise'.)
Supervision of exercise by an athletic trainer or physical therapist may help to mitigate the risk of injury by ensuring that the patient maintains correct physical form and proper movement patterns. (See "Physical activity and exercise in older adults", section on 'Developing an activity plan' and "Exercise prescription and guidance for adults", section on 'Strategies to reduce risk during exercise'.)
Formulating an individual exercise plan — All patients with subacute and chronic LBP will likely benefit from physical activity. A patient's individual exercise ability and tolerance should be considered when making exercise program recommendations. Some patients may never have participated in exercise, while others may have stopped or greatly diminished physical activities and exercise because of their pain. Patient preference and ability will also guide recommendations for independent versus supervised exercise programs.
●Patient factors – When formulating an individual exercise plan, we consider the following:
•Current level of physical activity
•Current or previous types of exercise/exercise experience
•Interest in starting exercise
•Interest in supervised versus independent exercise
•Exercise options available within the patient's community
•Insurance coverage for exercise therapy and/or cost
●Degree of supervision – Patients who are already active and exercising independently should be encouraged to continue.
Patients who have never been active may benefit from a supervised, graded program with more support. Patients interested in supervised or group exercise may be more comfortable when recommended programs are matched with their abilities and exercise experience [46]. (See 'Selected exercise modalities' below.)
Patients with significant functional impairment, deconditioning, or fear avoidance of movement may also benefit from a more structured, guided approach to exercise initiation. For these patients, a referral to physical therapy for formal exercise instruction and education is reasonable.
●Referral specifications – For patients in whom supervised physical therapy is recommended, we find it helpful to specify expectations in the physical therapy referral, as without a detailed prescription, some patients may receive a one-time evaluation only, which may be insufficient.
As an example, in our physical therapy prescription, we typically request an "active exercise program including quota-based, non-pain-contingent, progressive stretching, lifting, and back strengthening," to emphasize the following:
•Quota based – In quota-based exercise, participants perform a predetermined "quota" of activity during scheduled sessions. Exercise intensity and resistance quotas are increased at regular intervals (usually every session or two), to achieve goal exercise and exertion levels.
•Non-pain contingent – With non-pain-contingent exercises, the planned activity is attempted even when mild or moderate pain is present.
In contrast to active therapy, passive modalities (superficial heat, cold, electrical stimulation, etc) and manual treatment are of limited benefit in patients with subacute and chronic LBP and may inadvertently discourage activity and exercise [47].
We also advise exercises that simulate real-life movements (eg, progressive trunk, back, and leg strengthening and lumbar lifting from floor to waist) and a lifting goal of up to 20 percent ideal body weight as tolerated. These specifications support active engagement, assist with fear and pain avoidance desensitization, and emphasize progressive physical activity as a key component of LBP treatment [48-51]. (See 'Exercise improves symptoms in subacute and chronic low back pain' above.)
Each physical therapy protocol should be customized for each patient, which may include details as described above, in addition to the evaluative process performed by the therapist. For complicated patients for whom the details of an optimal therapy protocol are unclear, a consultation with a physical medicine and rehabilitation specialist should be considered.
Selected exercise modalities — No single exercise technique has superiority over others for patients with subacute and chronic LBP [52]. Studies comparing exercise modalities have been inconclusive due to low quality of evidence and risk of bias. As an example, in a network meta-analysis of 217 trials evaluating specific exercises recommended by clinicians to address chronic LBP in over 20,000 patients, three exercise modalities (Pilates, McKenzie therapy, functional restoration) had greater benefit in improving pain intensity and functional limitations compared with other exercise treatments [53]. However, limitations included within-study risk of bias and heterogeneity.
All of the exercise approaches listed have demonstrated modest effects for reducing the pain and disability associated with LBP, without strong evidence for the superiority of any type of exercise. While anecdotal reports may suggest "matching" subgroups of LBP patients to specific exercise programs results in improved clinical outcomes, the literature provides conflicting evidence about subgrouping patients, and we do not support this approach. Instead, the decision for which specific type of exercise to recommend should be based on patient preference, cost, convenience, local availability, and clinician experience.
In order of increasing complexity and supervision, some of the more popular and widely available exercise approaches for LBP are reviewed here:
●Walking – Walking, the simplest and most readily available form of exercise, may be effective in decreasing symptoms of different types of chronic musculoskeletal pain, including LBP.
In a meta-analysis of 19 randomized trials, walking and running were slightly more effective than no intervention in improving chronic LBP symptoms but were slightly less effective than stabilization exercises, physical therapy, tai chi, or other general exercise [54].
●Aerobic exercise – Aerobic exercise is effective in decreasing symptoms of LBP. In a meta-analysis of eight cohort studies evaluating a variety of aerobic exercises (including bicycling, swimming, treadmill walking, and elliptical trainers), aerobic exercise was associated with decreased pain intensity and improved physical functioning over time in patients with chronic LBP [55].
In a subsequent meta-analysis of six randomized studies comparing progressive aerobic exercise with progressive resistance exercise in patients with chronic LBP, the two different exercise programs were equally effective in reducing back pain [56].
●Stretching exercises – There are a wide range of stretching exercises and programs available for patients with LBP, including both independent and guided stretching. Participation in a variety of different stretching programs may be beneficial in reducing symptoms in patients with chronic LBP as demonstrated in two randomized trials incorporating common leg and trunk stretches [57,58].
In addition, in a randomized trial of office workers with neck, shoulder, and low back pain, group exercise sessions consisting of back and general stretching combined with ergonomic worksite modifications were superior to worksite modifications alone in pain reduction at six months [59].
●Pilates – Pilates is a technique of exercise that focuses on performing controlled movements of the whole body that start with the core (back and abdomen) and flow outward towards the limbs. Proponents report health benefits, including body alignment, improved breathing, strength, coordination, and balance. Pilates can be adapted to patients with varying levels of fitness, with techniques that have been adapted to treat LBP.
Pilates may be similar in efficacy to other exercise regimens for the treatment of LBP [60,61]. In a systematic review including 29 randomized trials, Pilates was no more effective than any other exercise for the treatment of chronic LBP [60]. In another randomized trial of patients with LBP, participating in Pilates sessions two and three times per week resulted in greater reduction of pain and disability than participating in once-weekly Pilates sessions [62].
●Yoga – Yoga is a mind-body practice with three main components: physical poses/postures, breathing control, and meditation/relaxation. Yoga can be adapted for patients of different fitness levels and skills and is beneficial in managing symptoms in patients with chronic LBP. As an example, in a meta-analysis of 21 randomized trials, yoga produced small improvements in pain and function compared with nonexercise controls [63]. Yoga also was associated with small improvements in pain, although the effect did not reach the threshold for clinically meaningful improvement. Yoga was not more effective compared with other non-yoga exercises for improvement in function in patients with chronic LBP. (See "Overview of yoga".)
●Tai chi – Tai chi is a mind-body exercise characterized by flowing movements that emphasizes balance, focus, fitness, and breathing, and it can be helpful in the management of LBP. Tai chi can be practiced by individuals of varying fitness levels and skills; for this reason, it may be less likely to result in injury among older patients with LBP.
In a systematic review of randomized trials of patients with chronic pain, two of the three studies done on patients with LBP showed that tai chi plus physical therapy was modestly more effective than physical therapy alone [64]. In a subsequent meta-analysis of randomized trials evaluating the effects of yoga, Qigong, and tai chi on chronic LBP, all forms of exercise were beneficial in symptom management, while those participating in tai chi experienced the greatest reduction in pain intensity [65].
●Alexander Technique – The Alexander Technique involves providing individualized, hands-on instruction to improve balance, posture, and coordination; education about harmful habits; and muscle-use education to avoid painful movements.
In a randomized trial of 479 patients with chronic or recurrent LBP, participation in 24 sessions of the Alexander Technique was moderately effective in improving pain and disability at 12 months [66]. Receiving six sessions alone without any other treatment was ineffective, but the combination of home-based exercise and six Alexander Technique sessions resulted in moderate reduction in pain and disability and was more cost effective compared with usual care or massage therapy.
●Directional preference – Directional preference is an approach to the treatment of LBP based upon the theory that, in many patients with LBP, movement in a certain direction is the primary pain generator. Directional movement that causes pain to increase or radiate away from the midline should be avoided in favor of movement that lessens or "centralizes" (moving towards the midline) pain. Exercise is then prescribed based upon these observations. Directional preference techniques rely upon the assessment of a physical therapist or other trained provider and emphasize instruction in self-care.
For patients with chronic LBP, directional preference exercise may be marginally better at improving pain and function compared with advice to stay active but is not superior to other forms of exercise [67-71].
●Motor control, core, and spine stabilization exercise – Core exercise and spine stabilization exercise (also referred to as motor or movement control exercise) describe exercises that aim to activate, control, and coordinate the deep muscles of the spine, abdomen, and pelvis. The exercises are initially performed at rest, then at rest in different positions, followed by adding movement, activity, and more complex functional tasks. Core exercises may be more beneficial compared with no exercise for LBP but not compared with other exercise types [72-76].
There are variations of core exercise which attempt to fine-tune this approach (low-load motor control versus high-load lifting [77,78]; stabilizing exercise in the prone, supine, or combined prone and supine position [79]; stabilization combined with precise motor control of the trunk [80]; or stabilization combined with greater hip strengthening [81]).
The results of these variations of core exercise programs in patients with LBP are mixed. One systematic review of 29 randomized trials concluded that motor control exercise was not superior to other forms of exercise for management of chronic LBP [82]; other meta-analyses have suggested that motor control exercise may be more effective than other interventions for improving short- and long-term disability [83,84]. However, methodologic limitations of the included studies preclude firm conclusion.
●Graded activities exercise/back boot camp/functional restoration – These methods refer to exercise that begins with low-resistance strengthening with progressive increases in resistance at each session. Resistive equipment includes focused machines (back and leg) as well as whole body equipment. Aerobic and stretching exercises are also introduced in a progressive fashion. This technique is also known as progressive-resisted or quota-based strengthening. The progression of exercise and resistance proceeds even in the setting of pain, including pain flare-ups, as long as the pain is tolerable. Pain is expected during and after a session; through this technique, pain decreases as exercise desensitizes the pain-producing processes [11]. Treatment is usually delivered in 8 to 12 physical therapy sessions over four to six weeks [48,85].
This type of exercise intervention is typically delivered using a cognitive behavioral approach, which includes education regarding the safety of performing exercise while experiencing pain symptoms; support and praise for successful participation; and challenge and encouragement to achieve desired functional, recreational, and life goals.
This intervention focuses on restoring optimal back and life function and may be used for injured workers. (See "Occupational low back pain: Evaluation and management", section on 'Functional restoration'.)
In a systematic review of six randomized trials comparing graded therapies (progressive resistance training and progressive aerobic training) in patients with chronic LBP, both therapies were superior to usual care for pain reduction, but neither was superior to the other [56]. In addition, in one trial, graded exercise was no more effective than physical therapy-based exercise in pain reduction at three or six months [86]. Though endurance, flexibility, and strength may improve with this type of treatment, the degree of back pain improvement shows weak or no correlation with changes in any of these physiologic parameters [87]. Thus, it is likely that pain improvement resulted from more generalized benefits of exercise. (See 'Exercise improves symptoms in subacute and chronic low back pain' above.)
●Multidisciplinary (interdisciplinary) rehabilitation – Multidisciplinary, or interdisciplinary, rehabilitation combines (at a minimum) an exercise and a behavioral component provided by different health care professionals. The intensity and content of interdisciplinary therapy varies widely. These programs combine graded exercise therapy with a psychosocial approach, generally involving a psychologist. Multidisciplinary therapy can be similar to functional restoration programs but emphasizes multiple providers and behavioral interventions. This is discussed separately.
The exercise components of spine stabilization, functional restoration, and multidisciplinary rehabilitation are similar.
EXERCISE AND THE PREVENTION LOW BACK PAIN — Participation in exercise may prevent incident episodes of LBP as well as recurrence of LBP [88].
Primary prevention of low back pain — Among individuals without previous back pain, participation in any exercise may reduce the risk of developing LBP [89,90].
In a meta-analysis including 13 randomized trials and three nonrandomized trials, exercise was found to reduce the relative risk of developing LBP by 33 percent (risk ratio [RR] 0.67, 95% CI 0.53-0.85); both the severity of pain and back-related disability were also lower in the exercise group [90]. Strengthening combined with stretching or with aerobic exercises performed two to three times per week was felt to be an effective regimen in preventing LBP. The addition of an education component to exercise did not clearly improve outcomes.
Preventing recurrent episodes of low back pain — Exercise therapy may have a role in secondary prevention, particularly for those with recurrent episodes of LBP. A variety of types of exercise are beneficial, indicating that the specific activity may be less important than activity participation in general [45,91].
A meta-analysis of randomized studies examined the effects of exercise and exercise plus education in those with a history of LBP (but without significant LBP at baseline) [91]. The risk of recurrent LBP was decreased with exercise (four trials, 898 participants; 15 versus 25 percent; RR 0.65, 95% CI 0.50-0.86) and exercise plus education (four trials, 442 participants; 21 versus 41 percent; RR 0.55, 95% CI 0.41-0.74). A variety of exercise programs were included in the studies; leisure-time physical activity was also effective in preventing LBP. Limitations in study design make these conclusions low certainty.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lower spine disorders".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Low back pain in adults (The Basics)" and "Patient education: Back exercises (The Basics)")
●Beyond the Basics topic (see "Patient education: Low back pain in adults (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Exercise therapy for nonspecific acute low back pain – We do not routinely refer patients with nonspecific acute low back pain (LBP) for exercise or physical therapy, as acute LBP (duration of symptoms less than four weeks) is usually self-limited in most patients and exercise treatment has not been shown to be more beneficial for acute LBP when compared with other acute treatments.
However, continued activity is important; patients with acute LBP should be advised to avoid bedrest and stay active. Patients may continue their usual exercise regimen as tolerated or try home-based exercises.
●Exercise therapy for nonspecific subacute and chronic low back pain – For all patients with nonspecific subacute (4 to 12 weeks) and chronic (more than 12 weeks) LBP, we suggest exercise therapy rather than no exercise (Grade 2B). (See 'Subacute and chronic low back pain' above.)
•Counseling and anticipatory guidance – Counseling patients regarding their expectations is essential prior to recommending and initiating an exercise or movement-based therapy program for LBP. In addition, providing motivation, addressing patient concerns, and educating about an expected short-term, mild increase in pain with exercise initiation increases compliance. (See 'Counseling and anticipatory guidance' above.)
As with any movement-based program, there are risks of injury and other adverse events that may occur with exercise. Patients may be at risk for musculoskeletal injuries to the hips, knees, and ankles, in addition to other general risks of exercise. (See 'Educate about risks and adverse effects' above and "Exercise for adults: Terminology, patient assessment, and medical clearance", section on 'Benefits and risks associated with exercise'.)
•Formulating an individual exercise plan – When formulating an individual exercise plan, we consider individual exercise ability, experience with exercise, preferences for supervised versus independent exercise, local availability, and cost.
For patients referred to physical therapy, a detailed prescription specifying minimum number of sessions, type of therapy activities, and goals for therapy can provide useful guidance for the physical therapist. (See 'Formulating an individual exercise plan' above.)
●All exercise modalities are beneficial – We strongly advise and encourage our patients with subacute and chronic LBP to participate in graded exercise and activities of their choice as tolerated. Available evidence suggests that physical activity and exercise are interventions with minimal adverse effects that may improve pain, function, and quality of life. No single exercise technique has superiority over others for patients with nonspecific subacute and chronic LBP. This may be because exercise in all forms has similar generalized effects on the abnormal neurologic and inflammatory processes associated with subacute and chronic LBP. (See 'Selected exercise modalities' above.)
Examples of exercise programs that are likely beneficial for patients with subacute and chronic LBP, in order of increasing complexity and supervision include:
•Walking
•Aerobic exercise
•Stretching
•Pilates
•Yoga
•Tai chi
•Alexander Technique
•Directional preference
•Motor control, core, and spine stabilization exercise
•Graded activities exercise/back boot camp/functional restoration
•Multidisciplinary (interdisciplinary) rehabilitation
●Exercise therapy to prevent nonspecific low back pain – Exercise may prevent incident LBP among those with no prior history of back pain.
In patients with recurrent LBP, we suggest exercise therapy to decrease the risk of future back pain episodes (Grade 2C). Studies show a variety of types of exercise are beneficial, indicating that the specific activity may be less important than activity participation in general. (See 'Exercise and the prevention low back pain' above.)
ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges James Rainville, MD, and Kevin Bernard, MD, who contributed to an earlier version of this topic review.
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