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 . Exercise is often recommended to patients with LBP because it reduces pain and helps maintain or restore flexibility, strength, and endurance . This topic will address the rationale and evidence pertaining to exercise in the treatment of nonspecific LBP.
Exercise-based therapy for LBP with lumbar radiculopathy and LBP due to spinal stenosis are discussed separately. (See "Acute lumbosacral radiculopathy: Treatment and prognosis", section on 'Physical therapy' and "Lumbar spinal stenosis: Treatment and prognosis", section on 'Physical therapy'.)
The evaluation of LBP and other treatment modalities for LBP are discussed elsewhere. As examples:
SUBACUTE AND CHRONIC LOW BACK PAIN: EXERCISE IS BENEFICIAL — Low back pain (LBP) is defined as acute (less than 4 weeks), subacute (4 to 12 weeks) or chronic (more than 12 weeks) according to the duration of symptoms. The role of exercise- or movement-based therapy in the management of LBP varies according to the duration of back pain symptoms.
In several systematic reviews, exercise modestly improved pain and function in patients with subacute and chronic LBP [3,6,7]. 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 .
Proposed mechanisms of benefit — Exercise therapy improves pain and function in patients with chronic LBP [3,6,7,9,10], although a single mechanism by which exercise improves symptoms is not clear. There are likely several mechanisms contributing to the derived benefit, including neurologic, musculoskeletal, and psychological.
Tissue injury causes complex changes within the peripheral and central nervous system. Injury-induced cell proliferation and neurotrophic factors may amplify the processing of pain from the originally injured tissue or body area and result in the perpetuation of pain symptoms [11,12].
In animal studies, exercise reverses some of these injury-induced neurologic changes in the sensory ganglia, spinal cord, and brain [13-16]. Exercise also improves behavioral markers of pain in the exercising animal [13-23]. In animals, the effects of exercise on pain appear to be generalized; various exercises, even exercise that excludes the injured body part, reduce evidence of pain in the affected region .
Indirect evidence based upon these animal studies suggests that exercise would induce similar changes in the peripheral and central nervous systems that contribute to the production, maintenance, and resolution of pain, including LBP. Additionally, human studies have found that elevated pro-inflammatory cytokines and oxidative stress accompany LBP, and exercise attenuates these inflammatory processes .
Exercise has positive effects on human muscle, joint, and intervertebral disc metabolism [26-28]. 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.
Exercise provides psychological benefits, including reductions in stress, anxiety, and depression [29-31]. 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 [32,33]. 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 . In addition, physical activity interventions can improve the perception of exercise self-efficacy in activity-restricted individuals .
Counseling and evaluation prior to starting exercise — Counseling patients regarding their expectations is essential prior to recommending and initiating an exercise- or movement-based therapy program for LBP. In addition, addressing patient fears and concerns and assessing fitness level, interests, prior participation in exercise, and availability of resources are necessary in formulating an appropriate exercise plan.
Motivational interviewing and motivational enhancement therapy techniques can improve exercise motivation and compliance in patients with chronic LBP . Health coaching for people with LBP with low recovery expectations can result in goal setting and action planning . Individuals with neuromusculoskeletal conditions including LBP report complex barriers, demotivators, and motivators to performing exercise . 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."
Patients with LBP wish to have 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 .
Addressing 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 [40-42].
We educate patients regarding incorrect assumptions about the role of structural back "abnormalities" as the cause of their back pain. Patients who have had prior imaging may misunderstand the importance of the anatomic variations that have been identified, such as desiccated, narrow, degenerating, bulging, or herniated discs; facet joint arthritis; ligamentum flavum hypertrophy; Schmorl's nodes; 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 [43,44]. Patients are educated that although these anatomic variations may persist, the pain can be well managed and resolve over time. (See "Evaluation of low back pain in adults", section on 'Limited utility of imaging' and "Treatment of acute low back pain", section on 'Patient education'.)
Patients may believe or have previously received advice that certain activities (eg, bending from the waist, twisting, lifting heavy items, exercise, and sports activities that stress the spine) are unsafe, particularly if those activities provoke discomfort. Providing education by offering a neurologic explanation for provoked pain as an abnormally low pain stimulus threshold may be helpful for some patients. It may also be helpful to challenge patient concerns such as having been told that they have an "unstable" spine; "misaligned" vertebrae, hips, and/or sacroiliac joints; or a leg length discrepancy. These “diagnoses” are usually incorrect and are not generally accepted as contributory to symptoms.
Possible temporary increase in low back pain with initiation of exercise — 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 . Increased LBP following exercise is common, usually benign, and simply indicates that the pain-producing tissues have been stimulated. Overall, when compared with non-exercising control populations, exercise does not appear to increase the risk of LBP exacerbations [2,45].
Evaluating exercise options — All patients with subacute and chronic LBP will likely derive benefit from physical activity, but there is significant variability in exercise ability and tolerance among patients, which should be considered when making exercise program recommendations. Some patients may never have been regularly physically active, while others may have stopped or greatly diminished physical activities and exercise because of their pain. Patients who have never been active should be encouraged to begin exercise but may benefit from a supervised graded program with more support. Patients who are already active and exercising should be encouraged to continue.
Exploration of the exercise options available within the patient's community, while taking into consideration their preferences, circumstances, fitness level, and exercise experiences, will help to determine the most appropriate exercise program . Referral to physical therapy for formal exercise instruction and education may be reasonable for some patients who might benefit from a more structured, guided approach such as those with subacute or chronic LBP and significant functional impairment, deconditioning, and fear-avoidance of movement. (See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment", section on 'Exercise therapy'.)
Possible risks of exercise — As with any movement-based program, there are risks of injury and other adverse events which may occur with exercise.
Patients may be at risk for musculoskeletal injuries to the hips, knees, and ankles. Other risks of exercise, including rare serious medical events (eg, arrhythmia, sudden cardiac death, and myocardial infarction), are discussed separately. The medical evaluation prior to recommending any exercise program for a patient is also reviewed elsewhere. (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'.)
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. Regardless of age, supervision of exercise by an athletic trainer or physical therapist may help to mitigate the risk of injury by ensuring that the patient maintains good physical form and proper movement patterns. (See "Physical activity and exercise in older adults", section on 'Developing an activity plan'.)
Choice of exercise: All programs are beneficial — No single exercise technique has superiority over others for patients with 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 'Proposed mechanisms of benefit' above.)
Comparisons between exercise modalities have been made. In a 2021 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 . However, results were reported with moderate certainty, and 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. However, no single approach has been shown to be more effective than any of the other approaches for all patients. Many physiotherapists anecdotally report that certain subgroups of LBP patients are more responsive to specific exercise programs, leading to the belief that proper subgrouping of LBP patients with “matched” exercises leads to better clinical outcomes. The literature provides conflicting evidence about subgrouping patients, and we do not support this approach. Thus, in the absence of strong evidence for the superiority of any particular exercise program or approach, the decision for which specific type of exercise to recommend should be a matter of patient preference and clinician experience.
In order of increasing complexity, 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 2015 meta-analysis of 26 studies (five studies included patients with only chronic LBP; other studies included patients with chronic LBP, knee osteoarthritis, and fibromyalgia), walking improved pain and function at 12 months .
In a subsequent 2017 meta-analysis, walking was similar to other types of exercise for improvement in pain and disability, but there was no further improvement with the addition of walking to a different exercise program .
●Aerobic exercise – Aerobic exercise is effective in decreasing symptoms of LBP. In a 2015 meta-analysis of eight cohort studies evaluating a variety of aerobic exercises (including bicycling, swimming, treadmill walking, and elliptical trainers), aerobic exercise decreased pain intensity and improved physical functioning over time in patients with chronic LBP .
In a subsequent 2018 meta-analysis of six 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 .
●Stretching exercises – There are a wide range of stretching exercises and programs available, both independent and guided, for patients with LBP. Participation in a variety of different stretching programs may be beneficial in reducing symptoms in patients with chronic LBP as demonstrated in two studies incorporating common leg and trunk stretches [53,54].
In addition, in a randomized controlled trial of office workers with neck, shoulder, and LBP, 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 .
●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 [56,57]. In a 2015 systematic review including 29 studies, Pilates was no more effective than any other exercise for the treatment of chronic LBP . 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 .
●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 2022 meta-analysis of 21 trials, yoga produced small improvements in pain and function compared with non-exercise controls . 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 2016 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 . In a 2019 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 .
●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 . 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. In a randomized trial of LBP patients who exhibited a directional preference, exercises matching this directional preference were more clinically effective than exercises in the opposite direction .
For patients with chronic LBP, directional preference exercise may be marginally better compared with advice to stay active but not compared with other forms of exercise [64-68].
●Core exercise and spine stabilization – 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 [69-73].
There are variations of core exercise which attempt to fine-tune this approach (low-load motor control versus high-load lifting [74,75]; stabilizing exercise in the prone, supine, or combined prone and supine position ; stabilization combined with precise motor control of the trunk ; or stabilization combined with greater hip strengthening ). The results of these variations of core exercise programs in patients with LBP are mixed. As examples, a 2016 systematic review concluded that motor control exercise was not superior to other forms of exercise for management of chronic LBP ; however, in a 2018 meta-analyses, movement control exercise (a variation of core strengthening and spine stabilization) was more effective than other interventions for improving short- and long-term disability, but it only reduced pain in the short term .
●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 during and after a session is to be expected and should decrease as exercise desensitizes the pain-producing processes . Treatment is usually delivered in 8 to 12 physical therapy sessions over four to six weeks [81,82].
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 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 . In addition, in one trial, graded exercise was no more effective than physical therapy-based exercise in pain reduction at three or six months . 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 physiological parameters . Thus, it is likely that pain improvement resulted from more generalized benefits of exercise. (See 'Proposed mechanisms of benefit' 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. (See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment", section on 'Exercise therapy'.)
The exercise components of spine stabilization, functional restoration, and multidisciplinary rehabilitation are similar.
ACUTE LOW BACK PAIN: NO BENEFIT FROM EXERCISE THERAPY — Acute low back pain (LBP; duration of symptoms less than four weeks) has a good prognosis. Exercise treatment has not been shown to be more beneficial for acute LBP when compared with other acute treatments [3,6,85]. (See "Treatment of acute low back pain", section on 'Exercise and physical therapy'.)
Patients with acute LBP should be advised to avoid bedrest and stay as active as possible . Patients who wish to exercise may continue to perform their usual exercise regimen or try home-based exercises as tolerated.
EXERCISE MAY HELP PREVENT LOW BACK PAIN — Participation in exercise may prevent incident episodes of low back pain (LBP) as well as recurrence of LBP .
Primary prevention of low back pain — Among individuals without previous back pain, exercise may reduce the risk of developing LBP. Representative studies include:
●In a 2017 meta-analysis of 36 prospective cohort studies including over 158,000 participants, involvement in sport or other leisure physical activity was associated with a reduced risk of frequent or chronic LBP in moderately or highly active individuals compared with inactive persons (risk ratio 0.89; 95% CI 0.82-0.97) . However, participating in physical activity was not associated with a lower risk of having short episodes of LBP.
●In a 2018 meta-analysis including 13 randomized controlled trials and three non-randomized controlled trials, exercise was found to reduce the risk of developing LBP by 33 percent (risk ratio 0.67, 95% CI 0.53-0.85), with both the severity of pain and back related disability also lower in the exercise group . Strengthening combined with stretching or 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 improve outcomes.
Preventing recurrent episodes of low back pain — Exercise therapy may have a role in secondary prevention, particularly for those with recurrent LBP. As examples:
●In a meta-analysis including nine observational studies, post-treatment exercises were more effective than no intervention for reducing the rate of LBP recurrence at one year (rate ratio 0.50, 95% CI 0.34-0.73) . The most promising approaches involved back flexibility and strengthening exercises.
●A subsequent meta-analysis including 23 studies and 31,000 participants examined the effects of exercise and exercise plus education in those with a history of LBP (but without significant LBP at baseline) . Compared with no exercise, both exercise (relative risk 0.65; 95% CI 0.50-0.86) and exercise plus education (relative risk 0.55, 95% CI 0.41-0.74) decreased the risk of recurrent LBP. A variety of exercise programs were included in the studies; leisure-time physical activity also appears to be effective in preventing LBP.
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".)
SUMMARY AND RECOMMENDATIONS
●Exercise recommended for subacute and chronic low back pain – The role of exercise- or movement-based therapy in the management of low back pain (LBP) varies according to the duration of back pain symptoms. For all patients with subacute (4 to 12 weeks) and chronic (more than 12) LBP, we recommend exercise therapy rather than no exercise (Grade 1B). (See 'Subacute and chronic low back pain: Exercise is beneficial' above and 'Prescribe exercise' above.)
●Exercise improves pain and function – Exercise therapy improves pain and function in patients with chronic LBP, although a single mechanism by which exercise improves symptoms is not clear. There are likely several mechanisms contributing to the derived benefit, including neurologic, musculoskeletal, and psychological. (See 'Proposed mechanisms of benefit' above.)
●Counseling, evaluation, and education are essential – Counseling patients regarding their expectations is essential prior to recommending and initiating an exercise- or movement-based therapy program for LBP. In addition, addressing patient fears and concerns and assessing fitness level, interests, prior participation in exercise, and availability of resources are necessary in formulating an appropriate exercise plan. (See 'Counseling and evaluation prior to starting exercise' above.)
●Potential risks – 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. Other risks of exercise, including rare serious medical events (eg, arrhythmia, sudden cardiac death, and myocardial infarction), are discussed separately. (See 'Possible risks of exercise' above and "Exercise for adults: Terminology, patient assessment, and medical clearance", section on 'Benefits and risks associated with exercise' and "The benefits and risks of aerobic exercise", section on 'Risks of exercise'.)
●All exercise programs are beneficial – No single exercise technique has superiority over others for patients with 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 'Choice of exercise: All programs are beneficial' above.)
Examples of exercise programs that are beneficial for patients with subacute and chronic LBP include:
•Core exercise/spine stabilization
•Graded activities exercise/back boot camp/functional restoration
•Multidisciplinary (interdisciplinary) rehabilitation
●Exercise not harmful, but of no benefit in acute low back pain – Acute LBP (symptom duration less than four weeks) has a good prognosis. Exercise treatment has not been shown to be more beneficial for acute LBP when compared with other acute treatments. Patients with acute LBP should be advised to avoid bedrest and stay as active as possible. Patients who do wish to exercise, however, may continue to perform their usual exercise regimen, as they can tolerate, or try home-based exercises. (See 'Acute low back pain: No benefit from exercise therapy' above.)
●Exercise helpful for primary and secondary prevention of low back pain – Exercise may prevent incident LBP among those with no prior history of back pain as well as recurrent back pain episodes among those with a history of previous LBP. (See 'Exercise may help prevent low back pain' above.)
ACKNOWLEDGMENT — 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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