Unique Considerations for Exercise Programs to Prevent Future Low Back Pain

The Patient Perspective

Julie Ayre; Hazel Jenkins; Kirsten J. McCaffery; Christopher G. Maher; Mark J. Hancock


Pain. 2022;163(8):e953-e962. 

In This Article

Abstract and Introduction


There is moderate quality evidence that exercise can help to prevent future low back pain (LBP). This study aimed to explore patient needs and preferences for exercise programs to prevent LBP and the outcomes of these programs that would be most important to a patient. Researchers conducted 26 semistructured interviews with people with LBP. Interviews were audio-recorded, transcribed, and analysed using framework thematic analysis. Three themes were developed. Theme 1 emphasised that everyone's LBP was different, translating to preferences for tailored prevention programs with a high level of initial supervision and individualised biomedical explanations for the program. Theme 2 highlighted important outcomes. Pain was considered not only for intensity but also for the duration, frequency, and severity of flare-ups or episodes. Other important outcomes were general fitness and capacity to engage in everyday activities, social interactions, and work. Theme 3 outlined aspects of exercise programs that were considered important for people with fluctuating pain, including how to foster a sense of "progress," set realistic expectations, and support patients to establish exercise routines that can adapt to fluctuating pain. Theme 4 discussed participants' desire for social connection. Patients want exercise programs for LBP prevention, which are highly individualised, provide meaningful explanations of exercises, and help them maintain exercise in the long-term. Clinicians should discuss with patients the transition from a focus on treatment to the prevention of LBP. This provides greater opportunity to adjust goals and expectations and provide relevant education. Balancing the need for individualised care against affordability presents an ongoing challenge.


Low back pain (LBP) is common and estimated to affect 7.3% of the global population at any given point in time.[35] This places a significant burden on both the individual and the healthcare system.[12,17] Although individual episodes of back pain often improve quickly, most people will experience either ongoing low to moderate levels of pain with regular flare-ups or periods of "recovery" (no pain) interspersed with regular recurrences.[14] In those who do "recover" from an episode, recurrence within 12 months is experienced by approximately two-thirds of people.[12]

Exercise is widely recommended for both treatment of chronic LBP and prevention of future LBP.[25] Systematic reviews indicate moderate quality evidence that exercise can help to prevent future LBP.[13,18,19,31] However, it is unclear how such prevention programs might best be implemented. Discrete choice experiments have identified a preference for aerobic exercise rather than strength training to prevent recurrence of LBP,[1] shorter program duration and travel time, lower cost, and programs taking place outside of a gym (eg, home, clinic, or community centre).[15] However, these studies did not consistently identify a preference for supervised over unsupervised programs or group over individual programs and can provide only high-level information about preferences. Although not specific to prevention, qualitative research on management of existing LBP suggests that barriers to engagement include lack of personalisation (to accommodate preferred type of exercise, patient fitness, and skill level), time-consuming or inconvenient programs, and inadequate supervision by a health professional.[30]

Exercise programs that specifically target prevention will also need to consider issues that play out long-term. This might include, eg, limited beliefs that exercise will prevent future back pain, low confidence for coping with recurrences, and low motivation to exercise when pain has receded.[3] Fear of recurrence may also lead to avoidant behaviour (reduced activity), potentially placing patients at greater risk of a recurrence.[3,11,34,38] Further research is needed to understand how these experiences translate to needs and preferences for engaging in prevention programs.

It is also important to identify which outcomes from an exercise program will be most meaningful for patients.[32] To date, interventions to reduce the future impact of LBP have predominantly focused on pain outcomes.[13] Standardised measures of pain or disability may not be adequate because they often do not correspond to descriptive accounts of pain.[7,20,39] Emotional or cognitive aspects of recovery may also be relevant, eg, pain acceptance and reduced fear of dependency on others.[6] Patients with LBP have also emphasised the importance of being able to engage in meaningful daily activities, work, and social roles.[20]

This study focused on people with recurrent LBP or low to moderate intensity pain with regular flare-ups. It aimed to explore needs, preferences, and outcomes that would matter most for patients receiving exercise interventions that aim to prevent or reduce future LBP.