Research continues to support the effectiveness of exercise when it comes to low back pain (LBP)—not only as a way to treat existing LBP, but as a way to prevent it.

A new systematic review and meta-analysis in JAMA Internal Medicine (abstract only available for free) assessed research into the value of exercise as a way to prevent episodes of LBP. It found that exercise alone was linked to a 35% reduction in risk, while a combination of exercise and education was associated with a 45% risk reduction for up to 1 year. The use of exercise was also found to result in a 78% reduction in sick leave for LBP.

The review was based on 23 published studies involving 30,850 participants, and looked at the preventive qualities not only of exercise and education (both combined and separately), but also of back belts and orthotic shoe insoles. In the end, only exercise was linked to a reduced risk of LBP: authors of the study found that while education helped to further reduce that risk when combined with exercise, education alone didn’t seem to have much effect.

The problem: the risk reduction benefits of exercise “disappeared” after 1 year. Authors attribute the dropoff to some individuals discontinuing the exercise program.

“The finding raises the important issue that, for exercise to remain protective against future LBP, it is likely that ongoing exercise is required,” authors write. “Prevention programs focusing on long-term behavior change in exercise habits seem to be important.”

Also Works for Treatment of Chronic LBP
While the JAMA authors focused on prevention, researchers whose findings were included in a recently updated Cochrane review ( currently, abstract only available for free; complete article will be made available via APTA’s ArticleSearch in the coming weeks) aimed at evaluating the evidence supporting exercise—specifically motor control exercise (MCE) to coordinate and stabilize deep trunk muscles—as a treatment for chronic LBP.

Their conclusion was that MCE “probably provides better improvements in pain, function, and global impression of recovery” than minimal intervention at all follow-up periods (these varied by study), and that it “may” provide better improvements than exercise and electrophysical agents. Authors found results to be about the same when it came to MCE versus manual therapy, and MCE versus “other forms of exercise.” The analysis was based on 29 trials involving 2,431 participants.

“Given the minimal evidence that MCE is superior to other forms of exercise, the choice of exercise for chronic LBP would probably depend on patient or therapist preferences, therapist training, costs, and safety,” authors write.

‘Uncommonly Prescribed’
In an invited commentary on the JAMA article, authors Timothy Carey, MD, and Janet Freburger, PT, PhD, focus on the LBP prevention study, but the main point they raise—the need for more widespread use of exercise prescriptions—could apply to the MCE study as well.

“If a medication or injection were available that reduced LBP recurrence by [the amounts cited in the JAMA article], we would be reading the marketing materials in our journals and viewing them on television,” commentary authors write. “However, formal exercise instruction after an episode of LBP is uncommonly prescribed by physicians.” They describe the gap as part of a pattern in the treatment of musculoskeletal problems “in which effective but lower-technology and often lower-reimbursed activities are underused.”

Carey and Freburger describe several barriers to more common use of exercise instruction that include a lack of consensus around “standard, efficient, and acceptable bundled intervention” for LBP, unclear understandings of the role of patient education, questions about how best to motivate patients, a paucity of cost-effectiveness studies, hesitancy among payers to support exercise programs, and a shortage of clinicians “able to describe, with confidence, the benefits of easily accessible exercise programs to diverse patient populations.”

“To address these barriers, payers, professional societies, consumers, and members of health care delivery systems will need to work together,” write Carey and Freburger, adding that if they do, “the potential benefits to the health system, patients, and employers are substantial.”

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association’s PTNow website.


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