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Exercise and Chronic Low Back Pain


9 July 2021


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Exercise is a key component of effective chronic lower back pain management.

Chronic low back pain (CLBP) is among the most common clinical, social, economic, and public health problems of all chronic pain disorders across the world [1]. In addition to its high prevalence, CLBP can be a severely disabling disorder characterized by tremendous personal and socioeconomic impact, with long-term sick-leave and low quality of life [2]. CLBP is the most common cause of work-related disability [3, 4], and it causes the highest number of years lived with disability [5, 6].

Beneficial effects of exercise therapy for chronic low back pain: Exercise is a key component of effective CLBP pain management. CLBP treatment guidelines recommend non-pharmacological and non-invasive management, including the advice to stay active, the use of patient education and exercise therapy [7]. Exercise therapy is an evidence based treatment for CLBP [8-10]. Although differences exist between CLBP guidelines, exercise therapy is recommended by all of them [11-14]. It has a number of potential benefits, including improving physical function, mood, sleep, stress tolerance and cognitive function, as well as decreasing the risk of secondary health problems including cancer, cardiovascular, metabolic, bone and neurodegenerative disorders [15]. Important for people with CLBP, there is a substantial and growing body of evidence that long-term exercise therapy can provide pain relief across many different chronic pain conditions, including CLBP [16, 17].  

What type of exercise therapy is beneficial for patients with chronic low back pain? All CLBP guidelines acknowledge that no one particular exercise modality is superior to others [11-14]. General, aerobic, strengthening/resistance, cognition-targeted, coordination/stabilization, motor control, yoga, group-based or individual exercises all generate beneficial effects in people with CLBP [8, 18-24]. In addition, compared to education or other types of exercise therapy, walking improves pain, disability, quality of life and fear-avoidance beliefs to a similar extent [25]. Based on the available evidence, walking interventions are not recommended as a sole treatment [25,26], but given the limited resources required for walking, it can be a valuable home-based addition to other treatment modalities [25, 27]. Since no one type of exercise therapy appears to be superior, clinicians are advised to consider the patient’s preferences, needs and capabilities when choosing the appropriate exercise type for their patients [26].

What kind of exercise therapy cannot be recommended for patients with chronic low back pain? However, not all exercise therapy has strong evidence of effectiveness for people with CLBP [26]. More specifically, back schools, sensory discrimination training, proprioceptive exercises, and sling exercise cannot be recommended due to lack of convincing evidence [28-31]. 

Exercise therapy as a key part of a multimodal approach for chronic low back pain: Patient’s expectations for care are often not limited to exercise therapy as a sole treatment, but rather include a multimodal approach. This is in line with the available evidence supporting the combination of exercise therapy with a psychological and/or a social/work targeted component (i.e. biopsychosocial approach) [32-24]. While there is no difference at short- and intermediate-term follow-up, behavioral psychological interventions appear to be more effective in reducing pain at long-term follow-up than active treatments without a psychological component [32]. 

Cognition-targeted exercise therapy, graded activity and graded exposure: Patients with CLBP may be hampered by maladaptive (pain) beliefs and irrational fear of certain body movements or physical activity. To address this debilitating aspect of the CLBP experience, treatment approaches such as cognition-targeted exercise therapy [35], behavioural graded activity [36] and graded exposure [37] are available. Cognition-targeted exercise therapy and graded exposure confront patients with movements and daily activities that are feared, avoided and/or painful, with the aim of deceasing fear of these movements and activities. The available evidence supports the use of these approaches. Cognition-targeted exercise therapy demonstrates superior results over pain-contingent exercise therapy in patients with CLBP [22]. Behavioural graded activity resulted in larger improvements in disability when compared to a waitlist or usual care (but not in comparison with other types of exercise therapy), and there is limited evidence suggesting that graded exposure is more effective than behavioural graded activity for improving disability and catastrophizing in the short term [38]. An individually tailored approach, with high feared activities addressed using graded exposure [39], and medium/low feared activities through behavioural graded activity [40] and/or exercise therapy, may be preferable. 


[1] Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet (London, England) 2021; 396(10267): 2006-17.

[2] Mutubuki EN, Beljon Y, Maas ET, et al. The longitudinal relationships between pain severity and disability versus health-related quality of life and costs among chronic low back pain patients. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation 2020; 29(1): 275-87.

[3] Andersson GB. Epidemiological features of chronic low-back pain. Lancet (London, England) 1999; 354(9178): 581-5.

[4] Waddell G, Burton AK. Occupational health guidelines for the management of low back pain at work: evidence review. Occupational medicine (Oxford, England) 2001; 51(2): 124-35.

[5] Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet (London, England) 2020; 396(10258): 1204-22.

[6] Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet (London, England) 2015; 386(9995): 743-800.

[7] O’Connell NE, Cook CE, Wand BM, Ward SP. Clinical guidelines for low back pain: A critical review of consensus and inconsistencies across three major guidelines. Best practice & research Clinical rheumatology 2016; 30(6): 968-80.

[8] Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: exercise therapy for nonspecific low back pain. Annals of internal medicine 2005; 142(9): 765-75.

[9] Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Annals of internal medicine 2005; 142(9): 776-85.

[10] van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol 2010; 24(2): 193-204.

[11] Bekkering GE, Hendriks E, Koes B, et al. Dutch Physiotherapy Guidelines for Low Back Pain; 2003.

[12] Wong JJ, Cote P, Sutton DA, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European journal of pain (London, England) 2016.

[13] Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of internal medicine 2017; 166(7): 514-30.

[14] National Institute for Health and Care Excellence. NICE guidelines: Low back pain and sciatica in over 16s: assessment and management. 2016; 2016.

[15] Pedersen BK, Saltin B. Exercise as medicine: evidence for prescribing exercise as therapy in 26 different chronic diseases. Scandinavian Journal of Medicine and Science in Sports 2015; 25(Suppl 3): 1-72.

[16] Hayden J, Van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non‐specific low back pain. Cochrane Database of Systematic Reviews 2005; (3).

[17] van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Practice & Research Clinical Rheumatology 2010; 24(2): 193-204.

[18] Wewege MA, Booth J, Parmenter BJ. Aerobic vs. resistance exercise for chronic non-specific low back pain: A systematic review and meta-analysis. Journal of back and musculoskeletal rehabilitation 2018; 31(5): 889-99.

[19] Saragiotto BT, Maher CG, Yamato TP, et al. Motor Control Exercise for Nonspecific Low Back Pain: A Cochrane Review. Spine (Phila Pa 1976) 2016; 41(16): 1284-95.

[20] Yamato TP, Maher CG, Saragiotto BT, et al. Pilates for Low Back Pain: Complete Republication of a Cochrane Review. Spine (Phila Pa 1976) 2016; 41(12): 1013-21.

[21] Searle A, Spink M, Ho A, Chuter V. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clin Rehabil 2015; 29(12): 1155-67.

[22] Malfliet A, Kregel J, Coppieters I, et al. Effect of Pain Neuroscience Education Combined With Cognition-Targeted Motor Control Training on Chronic Spinal Pain: A Randomized Clinical Trial. JAMA Neurol 2018; 75(7): 808-17.

[23] 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 randomized trial. Pain 2007; 131(1-2): 31-7.

[24] Unsgaard-Tondel M, Fladmark AM, Salvesen O, Vasseljen O. Motor control exercises, sling exercises, and general exercises for patients with chronic low back pain: a randomized controlled trial with 1-year follow-up. Physical therapy 2010; 90(10): 1426-40.

[25] Vanti C, Andreatta S, Borghi S, Guccione AA, Pillastrini P, Bertozzi L. The effectiveness of walking versus exercise on pain and function in chronic low back pain: a systematic review and meta-analysis of randomized trials. Disability and rehabilitation 2019; 41(6): 622-32.

[26] Malfliet A, Ickmans K, Huysmans E, et al. Best Evidence Rehabilitation for Chronic Pain Part 3: Low Back Pain. Journal of clinical medicine 2019; 8(7).

[27] Sitthipornvorakul E, Klinsophon T, Sihawong R, Janwantanakul P. The effects of walking intervention in patients with chronic low back pain: A meta-analysis of randomized controlled trials. Musculoskeletal science & practice 2018; 34: 38-46.

[28] Parreira P, Heymans MW, van Tulder MW, et al. Back Schools for chronic non-specific low back pain. The Cochrane database of systematic reviews 2017; 8: Cd011674.

[29] Kalin S, Rausch-Osthoff AK, Bauer CM. What is the effect of sensory discrimination training on chronic low back pain? A systematic review. BMC Musculoskelet Disord 2016; 17: 143.

[30] Yue YS, Wang XD, Xie B, et al. Sling exercise for chronic low back pain: a systematic review and meta-analysis. PLoS One 2014; 9(6): e99307.

[31] McCaskey MA, Schuster-Amft C, Wirth B, Suica Z, de Bruin ED. Effects of proprioceptive exercises on pain and function in chronic neck- and low back pain rehabilitation: a systematic literature review. BMC Musculoskelet Disord 2014; 15: 382.

[32] Zhang Q, Jiang S, Young L, Li F. The Effectiveness of Group-Based Physiotherapy-Led Behavioral Psychological Interventions on Adults With Chronic Low Back Pain: A Systematic Review and Meta-Analysis. American journal of physical medicine & rehabilitation 2019; 98(3): 215-25.

[33] van Erp RMA, Huijnen IPJ, Jakobs MLG, Kleijnen J, Smeets R. Effectiveness of Primary Care Interventions Using a Biopsychosocial Approach in Chronic Low Back Pain: A Systematic Review. Pain practice : the official journal of World Institute of Pain 2019; 19(2): 224-41.

[34] Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ (Clinical research ed) 2015; 350: h444.

[35] Nijs J, Lluch Girbes E, Lundberg M, Malfliet A, Sterling M. Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Manual therapy 2015; 20(1): 216-20.

[36] Macedo LG, Latimer J, Maher CG, et al. Motor control or graded activity exercises for chronic low back pain? A randomised controlled trial. BMC musculoskeletal disorders 2008; 9: 65.

[37] Vlaeyen JW, de Jong J, Geilen M, Heuts PH, van Breukelen G. The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo. The Clinical journal of pain 2002; 18(4): 251-61.

[38] López-de-Uralde-Villanueva I, Muñoz-García D, Gil-Martínez A, et al. A Systematic Review and Meta-Analysis on the Effectiveness of Graded Activity and Graded Exposure for Chronic Nonspecific Low Back Pain. Pain Medicine 2016; 17(1): 172-88.

[39] Schemer L, Schroeder A, Ørnbøl E, Glombiewski JA. Exposure and cognitive-behavioural therapy for chronic back pain: An RCT on treatment processes. European journal of pain (London, England) 2019; 23(3): 526-38.

[40] Staal JB, Hlobil H, Köke AJ, Twisk JW, Smid T, van Mechelen W. Graded activity for workers with low back pain: who benefits most and how does it work? Arthritis and rheumatism 2008; 59(5): 642-9.


Prof. Dr. Jo Nijs
Professor, Vrije Universiteit Brussel
Physiotherapist, University Hospital Brussels
Pain in Motion Research Group


Michele Sterling, PhD
Recovery Injury Research Center
The University of Queensland

Saurab Sharma, PT, PhD
Postdoctoral Fellow
Neuroscience Research Australia

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