Evidence-based practice: Exercise as a treatment for lower back pain
Low back pain gets most of us at some point, so, asks Dr Mark McKean PhD, how do various forms of physical activity stack up in terms of exercise therapy?
Non-specific low back pain can result from a range of injuries and conditions, and can include symptoms such as pain, tingling, numbness and weakness in the legs. Commonly these issues relate to narrowing of the spinal canal, degeneration of the spine by wear and tear on joints, pressure on the nerve where it leaves the spine, disc degeneration, osteoporosis and some genetic conditions. In a 2014-2015 survey, 16% of Australians reported back problems, and nearly one million people reported some level of limitation in various activities as a result of this back pain. The Medical Journal of Australia suggests that up to 80% of Australians will experience back pain at some point in their lives and 10% will experience significant disability as a result.
With these statistics, it’s almost guaranteed that most exercise professionals will deal with clients that have suffered low back pain at some point. The varied nature of low back pain and severity of symptoms means that when managing these clients it is often a matter of what they can do rather than what they can’t. Exercise has been promoted as a ‘cure’ but the reality is that the types of exercise, training volume and loads, as well as frequency of exercise, is not well known or even available to the fitness professional. Certainly, if you have a client with low back pain you should have their medical professional confirm that the client can exercise and that there are no obvious or medical reasons that should restrict their exercise.
Nearly all scientific systemic reviews and meta-analyses in the literature show that using exercise as an intervention results in significantly lower back pain than other treatments, or no treatment. In fact, Searle et al. (2015) stated ‘Our results found a beneficial effect for strength/resistance and coordination/stabilisation exercise programs over other interventions in the treatment of chronic low back pain and that cardiorespiratory and combined exercise programs are ineffective’. Let’s look at the current forms of exercise and the outcomes in the research.
Pilates, yoga and tai chi
Yoga and Pilates have become common forms of exercise for people with low back pain. Due to the heightened fear of pain associated with fast or unexpected movements in people with low back pain, the slower more controlled actions involved in these forms of exercise appear to provide confidence that they may suffer less pain and be better able to complete the activity. Common issues associated with these types of research include a lack of detail around frequency, intensity and volume of the activity, which make it hard to prescribe a specific training guideline for these activities.
Gagnon et al. (2005) and Pereira et al. (2012) agreed that there was no difference between the Pilates method and other lumbar stabilisation training, suggesting the activities were similar even if the language used was different. The systematic review by Patti and colleagues (2015) concludes by saying that Pilates is more effective than minimal exercise, but it’s still not clear which part of the Pilates program actually improves low back pain. Wells et al. (2014) finish their review into the effectiveness of Pilates in people with low back pain by suggesting future research needs to better define the actual program so that clearer conclusions can be drawn about which activity in Pilates may be the cause of the changes seen.
Cramer et al. (2013) conducted a systematic review and meta-analysis of yoga for low back pain. Starting with only 10 randomised control trials and 967 low back pain sufferers as subjects, the conclusion was that yoga had good evidence to support its use in improving short and long-term pain, as well as back-specific disability, and was not associated with any adverse events during the intervention. Further, compared with education alone, yoga was associated with lower short-term pain intensity, although the effects were small.
Three papers reported tai chi having a positive effect on pain levels when compared with control groups or no tai chi. The studies lasted 10, 24 and 28 weeks respectively, and all reported a significant improvement in low back pain.
The aforementioned systematic review by Searle et al (2015) found a small but significant effect for strength/resistance training interventions in the treatment of low back pain when the training was focused on the whole body and trunk. This may have been due to the belief that reduced low back pain is not necessarily associated with any one muscle group and strength/resistance training that focused on the whole body and trunk used a wider range of muscles which may have improved function across the body. Interestingly, programs that used mainly cardiorespiratory exercise showed no effect in reducing low back pain.
Core stabilisation training
Core stabilisation and core stability training have also been promoted as ‘must do’ activities to help low back pain. Smith and colleagues (2014) performed a systematic review and meta-analysis on stabilisation exercise for low back pain. After reviewing 29 studies they concluded that while there was significant benefit to stabilisation training compared to control groups or alternative therapies, there was no difference between benefits of core stabilisation and any other form of active exercise in the long term. In fact, most systematic reviews looking at the outcomes from core stability training report inconclusive results due to the heterogeneity of all the studies where subject characteristics and the type of core stability exercises included are poorly reported. The systematic review by Stuber and colleagues (2014) suggests definitions of activity, as well as specific details regarding the populations and interventions, need to be improved before any real conclusions can be drawn as to the value of core stability for athletes with low back pain.
Research into this area has looked at scenarios in which subjects actively performed balance and perturbation exercises and postural control exercises. Exercises on vibration platforms were excluded. Most interventions with proprioceptive training elements did report some reduction in pain and improvement of functional status, but due to the low quality of such studies, no conclusions could be made for the benefits of this type of training.
There have been a large number of systematic reviews associated with exercise and low back pain. The interventions were broad and the descriptions of the types of activities, and duration and training load, were varied. This made it hard for many of the reviewers to state categorically that any one type of activity was more beneficial. However, what was agreed across nearly all of the reviews was that exercise in the forms described was better than no exercises or other alternate therapies. The bottom line for all fitness professionals is to engage clients that suffer from low back pain in guided exercise, as approved by their medical professional. This should comprise exercises for the whole body that are conducted in a controlled and progressive fashion to challenge the client bit by bit over time within the functional and pain-free limitations they can manage.
Dr Mark McKean PhD AEP CSCS is an Associate Professor (Adjunct) in sport and exercise science at USC, QLD.