Most Effective Exercise Program for Low Back Pain
Exercise is the most powerful wonder drug in America. In fact, the American College of Sports Medicine (ACSM) has launched a program called Exercise is Medicine with the sole purpose of getting Americans to incorporate physical activity and exercise into their daily routine, especially those people with health problems.

Exercise therapy has been shown effective with chronic low back pain (LBP). But physical therapists and other researchers are still grappling with what kind of exercise is best? Lately, there's been a trend to use stabilizing exercises during the early phases of recovery. This type of exercise program focuses on specific muscles of the abdomen and trunk. It helps reduce pain and improve function by controlling spinal segmental motion.

Studying exercise and back pain is a challenge. The patients are heterogenous (very different). So it's difficult to find a homogenous group to compare treatments with. Homogenous means they are more alike than different.

There are also many ways to study exercise. Should it be combined with other treatments such as manipulation or general exercises? Should patients receive additional information to help them understand back pain? Will adding this type of patient education improve the results of an exercise program or have any effect at all?

What about dividing patients up based on whether they work or not? Would that affect the results of an exercise program? There are many possible factors to consider in sorting out what type of exercise(s) work and with which patients.

In this study, working adults with recurrent nonspecific low back pain were placed in one of two treatment groups. By choosing patients who were still working, the authors created a more homogeneous group to study. Nonspecific means there was no medical cause for the back pain. It wasn't something serious like a tumor, fracture, or infection. With nonspecific low back pain, symptoms typically occur with active movement.

The patients were randomly placed in either a graded exercise program (the exercise group) or in a daily walking program (the reference group). A physical therapist supervised both groups for eight weeks. The graded exercise program focused on spinal stabilization. Graded means the exercises could be increased in number or difficulty when the patients' pain level decreased and when movement improved.

Each subject was given a specific program teaching them how to contract and hold stabilizing muscles. The exercises were done during daily activities and in a variety of different positions (sitting, standing, moving). Patients were taught how to activate the stabilizing muscles whenever they were in situations that might cause pain. Positions known to cause pain were avoided. Patients were encouraged to breathe correctly and avoid increasing abdominal pressure with breath holding.

The walking (reference) group was told about the benefits of daily walks. They were advised to walk as fast as was comfortably possible without setting off their pain for a total of 30-minutes every day. If pain developed or increased, they were to slow down. The 30-minute walk could be done in two sessions of 15 minutes each.

Results of the two programs were compared using several different measures. The main measures of outcome were pain and perceived disability (measured by a self-reported survey filled out by each patient). The secondary measures included general physical health, ratings of self-efficacy (confidence to move and participate in activities), and fear-avoidance behaviors (FAB). Fear avoidance refers to patients avoiding movements or activities because these might increase their pain.

Everyone was followed for a total of three years with individual follow-up measurements taken at six-months, 12-months, and 36-months. At the end of the first year, half of the graded exercise group had more than a 50 per cent reduction in their pain. This was compared with only one-fourth of the walking (reference) group experiencing an equal amount of pain relief.

Both groups reported decreased disability, but there were more patients in the graded exercise group than in the walking group to report this result. Likewise, patients in both groups experienced improved general health. Only the exercise group reported a decrease in fear-avoidance and improved self-efficacy (confidence) behaviors.

More people in the graded exercise group stuck with the program (96 per cent) compared with the walking group (71 per cent). Fewer patients in the exercise group had a bout of recurrent low back pain during the first 12 months. But over the entire three-year period, recurrence of back pain was equal between the two groups.

The authors concluded that the graded exercise program had some benefits not seen with a simple walking program. The exercise group had a self-management strategy to use for pain and they were much more satisfied with the results. Patients in both groups did benefit -- just in different ways. It would be interesting to see if these two programs combined together would yield even better results than either group alone.

The authors suggest further studies are needed to continue looking for ways to reduce pain and disability in back pain patients. Finding a way to prevent back pain recurrence is one important goal. Preventing back pain from ever developing is another equally important goal. Pain and perceived disability are only two ways to measure the results of treatment. In a working group of adults, general health, freedom from fear to move, and confidence to do their job tasks are also very important.
Eva Rasmussen-Barr, RPT, MSc, et al. Graded Exercise for Recurrent Low-Back Pain. In Spine. February 1, 2009. Vol. 34. No. 3. Pp. 221-228.