Low back pain: Can exercise prevent recurrences?

Doing exercises regularly after having treatment for low back pain can help one out of every three people affected by this condition to prevent recurrences.

Pain in the lower back (the lumbar and sacral regions) is one of the most common types of pain. If it arises suddenly, it is also called “lumbago”. Most of the time, low back pain improves so much on its own within a few weeks that people can return to their usual everyday activities. In some people the pain lasts longer, though. It can also become physically disabling and a psychological burden.

The exact cause of low back pain is usually not clear, and it is then called “non-specific back pain”. It is thought that physical and psychological factors can both play a role.

Sometimes back pain has a specific cause, although this is not as common. Causes include problems affecting the bones, muscles or nerves of the spine. Tense muscles can irritate nerves and lead to pain, which may be felt in other parts of the body, too, like the legs (sciatic pain). Bad posture, inflammations or damage to a spinal disc can cause back pain too. You can find out more about how the spine works here.

Back pain is a very individual matter. It may be possible that during an examination no sign of anything wrong is found, yet someone is still in pain – while others can show signs of wear and tear of the spine on an x-ray but have no pain whatsoever.

Back pain is classified into three categories according to how long it lasts:

• acute back pain (less than 6 weeks)
• subacute back pain (6 to 12 weeks)
• chronic back pain (more than 12 weeks)

Sometimes back pain keeps returning; many people still have mild pain for a long time after an acute bout, or suddenly get severe back pain again after being pain-free for a while. If the pain returns after at least six pain-free months, it is called “returning” or “recurring” back pain. In about half of all people who have low back pain, the pain returns within a year.

In rare cases, back pain is caused by serious health problems. It may then be accompanied by other symptoms, such as numbness, paralysis, weakness, tingling sensations or urine and stool incontinence. If you have one of these symptoms, it is important to see a doctor at once.

Preventing recurring low back pain

A group of researchers from the Cochrane Collaboration – an international network of researchers – wanted to find out if physical exercise could prevent low back pain from recurring. They did a search for trials testing whether strength exercises, gymnastics and endurance training helped to prevent non-specific low back pain. In these trials volunteers were randomly divided into groups. These groups were then given different treatments and were then compared. You can read more about why trials are done this way here.

The researchers found nine trials involving a total of about 1,500 participants. The exercise programs in the trials started at different points in the treatment process: In five of the trials the participants already started doing exercises while they were still having treatment for acute pain. In the other four trials the participants only started doing exercises once the pain had improved. In most of the trials, the exercises were led by a physiotherapist. The exercise sessions lasted between 15 minutes and one hour, and the participants exercised several times a week for up to a few months. People whose back pain had a known cause, such as bone fractures, tumors or infections, did not participate in the trials.

It helps to do exercises once treatment is over

Exercises after treatment

In some trials the participants started doing special exercises led by a physiotherapist once their treatment for acute symptoms was completed. They were compared with a group of people who did not follow this kind of exercise program. The outcome: exercises led to fewer recurrences of low back pain in the first two years. In two smaller trials researchers tested a program using regular exercise following treatment of acute symptoms and looked at how many of the participants had low back pain returning within the first two years:

• 33 out of 100 people in the exercise group had a further bout of low back pain.
• 65 out of 100 people who did not do exercises had a further bout of low back pain.

Other small-scale trials that tested using a regular exercise program after treatment of acute symptoms looked at how often people took sick leave from work. The researchers found that those who had the exercise programs took sick leave just as often as those who did not, but they did have fewer days of absence overall.

Exercises during treatment

Other trials looked at whether starting an exercise program earlier – while people are still being treated for acute pain – can help prevent low back pain in the longer term. The outcome was not clear: some trials found that this approach had advantages, but other trials did not. So it is still not known whether doing special exercises during the acute stage can prevent low back pain from recurring in the long term.

It is important to stay active at all stages

The results of the trials do not mean that there is no point in doing exercises during earlier phases of low back pain. On the contrary: it is important to stay active right from the start. Doing exercises early on helps to relieve the pain, but might not be enough to prevent the pain from coming back in the long term. The Cochrane researchers assume that people in early exercise programs like these often stop doing their exercises after a few weeks, when the pain gets better. So those programs do not lead to long-term changes in behavior. Exercise programs that start after the acute pain has gone away, however, try to do exactly that. This could possibly explain why they were found to be more effective in the trials. These trials did not report on adverse effects.

It is still not clear what types of exercises programs like this should ideally include. The decision about what treatment is the most appropriate will vary from person to person, depending on things like their level of fitness, other illnesses, how severe their pain is, as well as their personal preferences.


Author: Institute for Quality and Efficiency in Health Care (IQWiG)

© IQWiG (Institute for Quality and Efficiency in Health Care)