What’s the best exercise for lower back pain?
The need to treat lower back pain effectively
Lower back pain is extremely common. So common in fact that if you have not already done so, you will likely have an episode at some point in your life. Most of the time an episode will settle within 6 weeks but in a proportion of cases it can take longer, sometimes more than a year.
Lower back pain is so prevalent that it has been found to be the leading cause of disability worldwide. The cost to the NHS is in the region of £1 billion pound per year. The cost to employers is over £600 million and 119 work days per year.
Partly due to this economic burden there has been a lot of interest and research looking at the most effective treatments for lower back pain, and this blog will investigate the most appropriate form of exercise as a treatment.
Common exercise misconceptions
I hear lots of common misconceptions regarding low back pain and exercise and not just from clients! Until I developed a better understanding of the problem I was guilty of a variety of these myself. These include well intentioned advice such as to rest until the pain has gone, avoid lifting weights, avoid impact exercise, and that core stability and Pilates are best.
The first commonly held misconception would be that if you have lower back pain you should avoid exercise, and instead rest. Although, depending on your normal exercise levels, you may find relative rest helpful initially; long term avoidance of exercise is very unhelpful.
Various forms of exercise have been suggested as the best at different times and for different reasons. Some have promised to fix faulty posture or alignment; some have claimed to fix imbalances and instability. The evidence that these issues actually exist for people with low back pain does not stack up.
It would seem logical that to select the most appropriate form of exercise first we need to better understand the factors that influence lower back pain.
So what are the risk-factors behind lower back pain?
Rather than having things out of place, lacking balance or ”core” the vast majority of people who seek physiotherapy present with what’s called “non-specific” lower back pain. This means that there is no identifiable specific or serious medical problem causing their symptoms, much like many other common pains e.g. Headaches, neck and shoulder tension, etc .
Much like these other examples- the pain is influenced by various interconnected factors including:
· General Health
· Exercise levels and tolerance
· Outlook and beliefs
· Mental health and wellbeing
· Work and home life
As no one person is the same, and these influencing factors will vary from person to person, it would appear very hard to pick one type of exercise that will have the right impact for everyone. When choosing the best type of exercise it would seem appropriate to pick the one that has the biggest positive affect for all of these factors.
Core stability exercise
Surely core stability exercises are the best for lower back pain? Stabilization type exercises became highly popular in the nineties possibly as a result of findings from a study in 1996 which related delayed activation of deeper back muscles with pain. A more recent and larger study in 2010 challenged the findings of this study, and actually showed a trend for earlier activation in the painful group. It seems that the genie was already out of the bottle however. Numerous large reviews of the literature since have shown that although core stability exercises are effective in improving pain and disability they are no more effective than general exercise.
Well what about just getting stronger? Surely that will help. Well a study in 2015 showed that it does help but perhaps not in the way you would think. Those given strengthening exercises improved for pain, disability and quality of life however their measured strength did not actually improve! Maybe just exposing yourself to exercise is more important than actual changes in strength. These findings are backed up by research in other areas such as neck pain, which show that perhaps strangely giving squatting type exercises can help reduce neck pain!
The non-specific (mystical) effects of exercise
Most people would have some understanding of how exercise affects their exercise tolerance and general health, however it can also do much more. Participating in exercise that we enjoy and that challenges us can affect our attitudes and beliefs about activity and about our own capabilities, can improve our mental health and well-being, and can also have a positive affect on our work life balance- all risk factors for developing persistent back pain. As well as this when we exercise it affects our hormone levels and we produce powerful natural painkillers. More powerful than morphine! It’s hard to think of many other treatments that have all these beneficial affects.
Exercise for prevention of back pain
Interestingly a recent analysis of 16 studies has shown that a combination of strengthening and aerobic exercise can reduce the occurrence of low back pain by up to 30%. This ties in well with the World Health Organizations recommendation of a minimum of 150 mins moderate intensity exercise and 2 sessions of resisted exercise a week.
So the best type of exercise is……
The important points to take away are that any exercise is good, and aiming for the WHO’s minimum exercise recommendations is not only an effective treatment for lower back pain but also is effective in reducing the future occurrence of lower back pain.
If we look again at the factors that influence lower back pain and how highly individualized these are likely to be, then it would appear that the most important factors when choosing a type of exercise is making sure that it is:
· something that you have ready access to,
· something you will enjoy and find challenging
· something that you think you will stick to longer term
· something that meets the recommended minimum levels mentioned previously