Pain in Primary Care

Low Back Pain: Does Exercise Help? What Type?

Charles P. Vega, MD


October 29, 2021

Last month, I posted a case from my own practice to highlight issues of pain management in primary care. To recap: The patient was a 50-year-old construction laborer with new-onset low back pain without sciatica. I asked for, and received, numerous comments about my management of this patient.

Thank you for the many constructive comments. I was impressed by how many participants in this activity recommended nonpharmacologic management for back pain and shared their own, and at times very personal, perspectives on what works and what does not. Your suggestions prompted me to look further into exercise and physical therapy interventions for low back pain.

As mentioned in the original article, multiple different methods of exercise training are effective in the management of low back pain, and I stand by the statement that what really matters in recommending effective therapy is the patient's perspective and values as well as the resources that are most accessible for the patient.

Is Any Exercise Effective?

A network meta-analysis that included 89 randomized controlled trials compared the efficacy of different forms of exercise training in terms of pain and function among patients with low back pain, and the results of this study are illuminating.

The best interventions for reducing pain included Pilates and stabilization/motor control exercises, which focus on specific trunk muscles to improve coordination of the spine and pelvis (exercises which were promoted by numerous participants!) Aerobic exercise also improved pain.

For physical function, the top exercise treatment modalities were stabilization/motor control and resistance training, followed by water-based training, Pilates, and yoga. Researchers also evaluated mental health as an outcome, and resistance and aerobic training had the most positive effects in this domain. Finally, stabilization/motor control and resistance training were most effective for the outcome of muscle strength.

Stretching alone did not improve pain or physical function, nor did McKenzie exercises, which usually involve repeated passive spine movements and sustained positions in different directions.

Some respondents mentioned the world's number one preferred form of exercise — walking — for the management of low back pain. Could such a simple intervention be effective? The answer, according to another systematic review of randomized trials, is…maybe.

Five studies were included in the meta-analysis. Three studies compared walking with other forms of exercise, and two examined whether walking could offer additional benefit beyond other forms of exercise.

Overall, walking was similar to other forms of exercise in its effects on pain, disability, and quality of life. However, these effects were small and of questionable clinical significance. The authors note that the small sample sizes from included research might have resulted in a lack of power to demonstrate a more robust effect. In addition, they found that adding walking to standard exercises for low back pain did not improve outcomes.

Low Back Pain Guidelines

These studies validate current recommendations for patients with low back pain to remain active. Still, many providers do not follow guidelines for the management of low back pain (please do not order plain radiography routinely for acute or subacute low back pain).

The degree of nonadherence to recommendations for the management of low back pain is shocking. In a study of 410 physical therapists presented with clinical vignettes of common cases of low back pain, adherence to the American Physical Therapy Association guidelines for low back pain was 72.2% for a case of pain with lower-extremity involvement. But guideline adherence dropped substantially to 46.1% for a case of low back pain with coordination impairment and 29.5% for pain with fear-avoidance behavior.

What about physician adherence to guideline-based therapy for low back pain? Not good. Another study found that the overall rate of adherence to guidelines from the Agency for Healthcare Research and Quality among 720 physicians was 26.9% for a case of low back pain without sciatica, and a mind-blowing 4.3% in a case of low back pain with sciatica. Physicians with backgrounds in general practice and internal medicine were particularly prone to deviations from guideline-based therapy.

Good healthcare can absolutely act against guidelines for many excellent reasons. However, if fewer than 1 in 20 patients with low back pain featuring sciatica receive the most evidence-based and efficient therapy, something is very wrong. I hope that this article helps to promote an evidence-based as well as patient-centered approach to low back pain. Thank you again for your excellent input!


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