Exercise and the Prevention of Low Back Pain: Ready for Implementation

Acute low back pain (LBP) is common, with more than 80% of us experiencing at least one episode in our lives. It is painful, a common cause of time offwork, and interfereswith our ability toperformdailyactivities. Fortunately, most episodes of acute LBP are selflimited and improve with timeandconservative treatments.However, recurrence iscommon,withestimates ranging from24%to80%in the first year.1 After recovery, patients often query their health care professional on how to avoid future episodes of LBP. The wellconducted systematic reviewbySteffens andcolleagues2 providesuswith concrete evidenceon thevalueof exercise. They summarize several lowtomoderate-quality trials that examine the benefits of exercise andeducationonprimary and secondary prevention of LBP and sick leave due to LBP. The benefits were fairly consistent across studies, and the effect size was large enough to have clinical and policy importance. Exercise alone or in combination with education is effective for preventing LBP. The authors also assessed other interventions, including education without specific exercise instruction, orthotic insoles, and back belts. These other interventions demonstrated minimal, if any, evidence of benefit. The types of exercise instruction across these studies were variable, encompassing core exercises emphasizing the strengthening of back and abdominal muscles, stretching and spine range-of-motion exercises, and more general instruction in aerobic conditioning. Almost all of the education and exercise regimensassessedweresubstantial regardingthefrequencyand durationof the sessions. Theeffect sizeof the reduction in risk for subsequent LBP was impressive (approximately 25%40%), with some evidence of reduced use of sick leave. Longterm benefits were less certain, with several studies showing no effect after 1 year. This diminished benefit may be the result of reduced adherence to continued exercise beyond the intervention period. If amedicationor injectionwereavailable that reducedLBP recurrence by such an amount, wewould be reading themarketing materials in our journals and viewing them on television.However, formal exercise instruction after an episodeof LBP is uncommonlyprescribedbyphysicians. This pattern is, unfortunately, similar to other musculoskeletal problems in which effective but lower-technology and often lowerreimbursedactivities areunderused. Inone study,3 fewer than half of the patients with chronic LBP or neck pain who were surveyed received exercise instruction despite a good evidencebase for its effectiveness. Passive treatments (eg, physicalmodalities)with limitedevidenceofeffectivenesswererelatively commonlyused.4Howmightwe address barriers to the use of exercise instruction after LBP? Develop Standard Exercise Treatment Protocols Although the protective effect of the various interventions was similar, the types of exercise prescribed were different. Experts in physical medicine, physical therapy, and other fields must come to consensus regarding standard, efficient, and acceptable bundled interventions for LBP prevention. It might be unrealistic to come up with a “one-size-fits-all” intervention; however, determining the categories of exercise (eg, strengthening, stretching, and aerobic) and the appropriate frequency, dose, and intensity for each category would be a positive start.