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Exercise-based therapy for low back pain

Carol Hartigan, MD
James Rainville, MD
Section Editor
Steven J Atlas, MD, MPH
Deputy Editor
Howard Libman, MD, FACP


Low back pain (LBP) is the most common musculoskeletal complaint worldwide, with up to 85 percent of all people experiencing LBP during their lifetimes [1]. Exercise is often recommended to patients with LBP because it is thought to help maintain or restore flexibility, strength, and endurance [2]. This topic will discuss the rationale and evidence pertaining to exercise and nonspecific LBP.

Other treatments for LBP are discussed under the appropriate topics. As examples:

(See "Treatment of acute low back pain".)

(See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment".)

(See "Subacute and chronic low back pain: Nonsurgical interventional treatment".)

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Literature review current through: Nov 2017. | This topic last updated: Nov 21, 2017.
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  1. Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ 2003; 81:646.
  2. Rainville J, Hartigan C, Jouve C, Martinez E. The influence of intense exercise-based physical therapy program on back pain anticipated before and induced by physical activities. Spine J 2004; 4:176.
  3. Rainville J, Hartigan C, Martinez E, et al. Exercise as a treatment for chronic low back pain. Spine J 2004; 4:106.
  4. Woolf CJ. What is this thing called pain? J Clin Invest 2010; 120:3742.
  5. Kuphal KE, Fibuch EE, Taylor BK. Extended swimming exercise reduces inflammatory and peripheral neuropathic pain in rodents. J Pain 2007; 8:989.
  6. Mazzardo-Martins L, Martins DF, Marcon R, et al. High-intensity extended swimming exercise reduces pain-related behavior in mice: involvement of endogenous opioids and the serotonergic system. J Pain 2010; 11:1384.
  7. Stagg NJ, Mata HP, Ibrahim MM, et al. Regular exercise reverses sensory hypersensitivity in a rat neuropathic pain model: role of endogenous opioids. Anesthesiology 2011; 114:940.
  8. Chen YW, Li YT, Chen YC, et al. Exercise training attenuates neuropathic pain and cytokine expression after chronic constriction injury of rat sciatic nerve. Anesth Analg 2012; 114:1330.
  9. Cobianchi S, Casals-Diaz L, Jaramillo J, Navarro X. Differential effects of activity dependent treatments on axonal regeneration and neuropathic pain after peripheral nerve injury. Exp Neurol 2013; 240:157.
  10. Martins DF, Mazzardo-Martins L, Soldi F, et al. High-intensity swimming exercise reduces neuropathic pain in an animal model of complex regional pain syndrome type I: evidence for a role of the adenosinergic system. Neuroscience 2013; 234:69.
  11. Chen YW, Lin MF, Chen YC, et al. Exercise training attenuates postoperative pain and expression of cytokines and N-methyl-D-aspartate receptor subunit 1 in rats. Reg Anesth Pain Med 2013; 38:282.
  12. Detloff MR, Smith EJ, Quiros Molina D, et al. Acute exercise prevents the development of neuropathic pain and the sprouting of non-peptidergic (GDNF- and artemin-responsive) c-fibers after spinal cord injury. Exp Neurol 2014; 255:38.
  13. Luan S, Wan Q, Luo H, et al. Running exercise alleviates pain and promotes cell proliferation in a rat model of intervertebral disc degeneration. Int J Mol Sci 2015; 16:2130.
  14. Almeida C, DeMaman A, Kusuda R, et al. Exercise therapy normalizes BDNF upregulation and glial hyperactivity in a mouse model of neuropathic pain. Pain 2015; 156:504.
  15. Kim YJ, Byun JH, Choi IS. Effect of Exercise on µ-Opioid Receptor Expression in the Rostral Ventromedial Medulla in Neuropathic Pain Rat Model. Ann Rehabil Med 2015; 39:331.
  16. Chuganji S, Nakano J, Sekino Y, et al. Hyperalgesia in an immobilized rat hindlimb: effect of treadmill exercise using non-immobilized limbs. Neurosci Lett 2015; 584:66.
  17. Cheng YY, Kao CL, Ma HI, et al. SIRT1-related inhibition of pro-inflammatory responses and oxidative stress are involved in the mechanism of nonspecific low back pain relief after exercise through modulation of Toll-like receptor 4. J Biochem 2015; 158:299.
  18. Choi BK, Verbeek JH, Tam WW, Jiang JY. Exercises for prevention of recurrences of low-back pain. Cochrane Database Syst Rev 2010; :CD006555.
  19. Machado LA, Maher CG, Herbert RD, et al. The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial. BMC Med 2010; 8:10.
  20. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev 2005; :CD000335.
  21. Chou R, Huffman LH, American Pain Society, American College of Physicians. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 2007; 147:492.
  22. Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev 2010; :CD007612.
  23. Searle A, Spink M, Ho A, Chuter V. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clin Rehabil 2015; 29:1155.
  24. Ferreira ML, Smeets RJ, Kamper SJ, et al. Can we explain heterogeneity among randomized clinical trials of exercise for chronic back pain? A meta-regression analysis of randomized controlled trials. Phys Ther 2010; 90:1383.
  25. Pinto RZ, Ferreira PH, Kongsted A, et al. Self-reported moderate-to-vigorous leisure time physical activity predicts less pain and disability over 12 months in chronic and persistent low back pain. Eur J Pain 2014; 18:1190.
  26. Slade SC, Patel S, Underwood M, Keating JL. What are patient beliefs and perceptions about exercise for nonspecific chronic low back pain? A systematic review of qualitative studies. Clin J Pain 2014; 30:995.
  27. O'Connor SR, Tully MA, Ryan B, et al. Walking exercise for chronic musculoskeletal pain: systematic review and meta-analysis. Arch Phys Med Rehabil 2015; 96:724.
  28. Meng XG, Yue SW. Efficacy of aerobic exercise for treatment of chronic low back pain: a meta-analysis. Am J Phys Med Rehabil 2015; 94:358.
  29. Steffens D, Hancock MJ, Maher CG, et al. Prognosis of chronic low back pain in patients presenting to a private community-based group exercise program. Eur Spine J 2014; 23:113.
  30. Yamato TP, Maher CG, Saragiotto BT, et al. Pilates for Low Back Pain: Complete Republication of a Cochrane Review. Spine (Phila Pa 1976) 2016; 41:1013.
  31. Mostagi FQ, Dias JM, Pereira LM, et al. Pilates versus general exercise effectiveness on pain and functionality in non-specific chronic low back pain subjects. J Bodyw Mov Ther 2015; 19:636.
  32. Wieland LS, Skoetz N, Pilkington K, et al. Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev 2017; 1:CD010671.
  33. Little P, Lewith G, Webley F, et al. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ 2008; 337:a884.
  34. Paatelma M, Kilpikoski S, Simonen R, et al. Orthopaedic manual therapy, McKenzie method or advice only for low back pain in working adults: a randomized controlled trial with one year follow-up. J Rehabil Med 2008; 40:858.
  35. Garcia AN, Costa Lda C, da Silva TM, et al. Effectiveness of back school versus McKenzie exercises in patients with chronic nonspecific low back pain: a randomized controlled trial. Phys Ther 2013; 93:729.
  36. Petersen T, Kryger P, Ekdahl C, et al. The effect of McKenzie therapy as compared with that of intensive strengthening training for the treatment of patients with subacute or chronic low back pain: A randomized controlled trial. Spine (Phila Pa 1976) 2002; 27:1702.
  37. Hosseinifar M, Akbari M, Behtash H, et al. The Effects of Stabilization and Mckenzie Exercises on Transverse Abdominis and Multifidus Muscle Thickness, Pain, and Disability: A Randomized Controlled Trial in NonSpecific Chronic Low Back Pain. J Phys Ther Sci 2013; 25:1541.
  38. Cho HY, Kim EH, Kim J. Effects of the CORE Exercise Program on Pain and Active Range of Motion in Patients with Chronic Low Back Pain. J Phys Ther Sci 2014; 26:1237.
  39. Cairns MC, Foster NE, Wright C. Randomized controlled trial of specific spinal stabilization exercises and conventional physiotherapy for recurrent low back pain. Spine (Phila Pa 1976) 2006; 31:E670.
  40. Koumantakis GA, Watson PJ, Oldham JA. Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Phys Ther 2005; 85:209.
  41. Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord 2014; 15:416.
  42. Aasa B, Berglund L, Michaelson P, Aasa U. Individualized low-load motor control exercises and education versus a high-load lifting exercise and education to improve activity, pain intensity, and physical performance in patients with low back pain: a randomized controlled trial. J Orthop Sports Phys Ther 2015; 45:77.
  43. Saner J, Kool J, Sieben JM, et al. A tailored exercise program versus general exercise for a subgroup of patients with low back pain and movement control impairment: A randomised controlled trial with one-year follow-up. Man Ther 2015; 20:672.
  44. Kendall KD, Emery CA, Wiley JP, Ferber R. The effect of the addition of hip strengthening exercises to a lumbopelvic exercise programme for the treatment of non-specific low back pain: A randomized controlled trial. J Sci Med Sport 2015; 18:626.
  45. Roche G, Ponthieux A, Parot-Shinkel E, et al. Comparison of a functional restoration program with active individual physical therapy for patients with chronic low back pain: a randomized controlled trial. Arch Phys Med Rehabil 2007; 88:1229.
  46. Rainville J, Jouve CA, Hartigan C, et al. Comparison of short- and long-term outcomes for aggressive spine rehabilitation delivered two versus three times per week. Spine J 2002; 2:402.
  47. Beasley M, Prescott GJ, Scotland G, et al. Patient-reported improvements in health are maintained 2 years after completing a short course of cognitive behaviour therapy, exercise or both treatments for chronic widespread pain: long-term results from the MUSICIAN randomised controlled trial. RMD Open 2015; 1:e000026.
  48. Richards MC, Ford JJ, Slater SL, et al. The effectiveness of physiotherapy functional restoration for post-acute low back pain: a systematic review. Man Ther 2013; 18:4.
  49. Steiger F, Wirth B, de Bruin ED, Mannion AF. Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. Eur Spine J 2012; 21:575.
  50. Steffens D, Maher CG, Pereira LS, et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med 2016; 176:199.
  51. Shiri R, Falah-Hassani K. Does leisure time physical activity protect against low back pain? Systematic review and meta-analysis of 36 prospective cohort studies. Br J Sports Med 2017; 51:1410.